Miller and Narahara ODs

Today's Date

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Phone

Home Phone

Cell Phone

Date of Birth

Occupation

Employer

Emergency Contact Name

First Last

Emergency Contact Phone Number

Date of Last Eye Exam

Dilated?

Yes
No

Referred By

Primary Vision Coverage

Secondary Coverage

Email Address

Medical Information

How is your general health?

Do you take medications for any of these systems? Please check yes or no.

Gastrointestinal

Yes
No

Ears/Nose/Throat

Yes
No

Cardiovascular

Yes
No

Respiratory

Yes
No

High Blood Pressure

Yes
No

Nervous

Yes
No

Urinary

Yes
No

Muscles/Bones

Yes
No

Integumentary (Skin)

Yes
No

Eyes

Yes
No

Endocrine (glands)

Yes
No

Blood/Lymph

Yes
No

Allergic/Immunologic

Yes
No

Headaches

Yes
No

Mental

Yes
No

Please Explain

Diabetes

Yes
No

Which Type?

Allergies to Medication(s)?

Yes
No

What medication(s) are you allergic to? Please also list your reaction(s).

Family History

High Blood Pressure

Yes
No

Relation?

Diabetes

Yes
No

Relation?

Glaucoma

Yes
No

Relation?

Macular Degeneration

Yes
No

Relation?

Retinal Detachment

Yes
No

Relation?

Cataracts

Yes
No

Relation?

Personal Eye Information

Do you have any eye conditions or problems?

Yes
No

What Kind?

Have you had any eye operations?

Yes
No

Macular Degeneration

Yes
No

Cataracts

Yes
No

Retinal Detachment

Yes
No

Dry Eyes

Yes
No

Blurred Vision

Yes
No

Do you wear glasses?

Yes
No

Contact Lenses?

Yes
No

What type of contact lenses do you wear?

Additional information?

Miller & Narahara ODs

Medical Information

Do you take medications for any of these systems? Please check yes or no.

Family History

Personal Eye Information