Optical Fashions Eye Care Clinic

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

Occupation

Employer

Insurance Company*

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

Member Name

Member Date of Birth

Member Number

Name of Family Physician

First Last

How Did You Find Out About Our Office?*

What Is Your General Health Status?*

List All Medications You Are Taking

Pharmacy Name

Pharmacy Phone Number

Medication Allergies

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

Are You Pregnant*

Yes
No

Name of Last Eye Doctor

First Last

Date of Last Eye Exam

If you are unsure, please give your best estimation.

Do You Wear Eyeglasses*

Yes
No

Do You Wear Contact Lenses?*

Yes
No

List All Current or Past Eye Diseases, Eye Injuries, or Eye Surgeries

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

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

Do You Use Tabacco Products?*

Current
Previous
Never

Do You Drink Alcohol?*

Socially
Daily
Never

Patient Eye Health*

Do You Currently Have*

Blurred Vision-Far
Blurred Vision-Near
Neither

Have You Ever Had*

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

Main Reason For Your Visit*

Exam
Medical Visit
Contact Lens Visit
Glasses Recheck

I am Interested In:

Glasses
Contact Lenses
Laser Surgery/LASIK
Other

Please specify 'Other'

Preferred Language:

English
Other
Decline

What is your preferred language?

Race:

White
African American
Asian
American Indian or Alaskan Native
Native Hawaiian or Pacific Islander
Other
Decline

Ethnicity:

Hispanic or Latino
Not Hispanic or Latino
Decline

Current Height:

Current Weight:

Any hobbies that affect you eyes/vision?