Optical Fashions Eye Care Clinic Patient Forms

Name*

First Last

Birthday*

Email*

Address*

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

Home Phone

Cell Phone

Have we examined other members of your family?*

Yes
No

Employer

Occupation

Insurance Company*

If you do not have insurance, please indicate with 'None'.

Member Name

Member Date of Birth

Member Number

Name of Last Eye Doctor

First Last

Clinic

Date of Last Eye Exam

If you are unsure please give your best estimation

May we contact them to obtain your last prescription?

Yes
No

Do you wear Eyeglasses?

Yes
No

Do you wear Contacts?

Yes
No

If so, what contact lenses do you wear?

Are you interested in contacts?

Yes
No

Would you like to be dilated at your exam?

Yes
No

We offer Clarus Photography which can be done instead or along with dilation to give the doctor a more complete view of your retinas. This does come with a charge that is non-submittable to insurance. Would you be interested in Clarus Photography?

Yes
No

Any hobbies that could affect your eyes/vision?

Yes
No

Comments:

How Did You Find Out About Our Office?*

If you are a Gundersen or Mayo Health System patient, can we access you medication list for you?

Yes
No

List all medications/vitamins that you are currently taking

Any known allergies (medication or other?)

Are you pregnant or nursing?

Yes
No

List All Major Illnesses, Injuries, Surgeries In The Last 10 Years

Family History (Family History includes your parents, siblings, and your children)

Cataract
Glaucoma
Diabetes
High Blood Pressure
Cancer
Macular Degeneration
None of the Above

Please indicate which family for each diagnosis that applies.

ex. Cataract - Mother

Please check any current eye issues:*

Have You Ever Had*

Lasik
Cataract Surgery
Lazy Eye
Eye Injury/Trauma
None of the Above

Comments: