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Optical Fashions Eye Care Clinic
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2017-07-06T01:14:26+00:00
Optical Fashions Eye Care Clinic
Name
*
First
Last
Birthday
*
MM slash DD slash YYYY
Email
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Address
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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
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If you do not have insurance, please indicate with 'None'.
Member Name
Member Date of Birth
MM slash DD slash YYYY
Member Number
How Did You Find Out About Our Office?
*
Insurance Company
Advertisement
Another Patient
Internet Search
Previous Patient
Other
If you are a Gundersen or Mayo Health System patient, can we access you medication list for you?
Yes
No
List All Medication/Vitamins You Are Taking
Medication Allergies
List All Major Illnesses, Injuries, Surgeries In The Last 10 Years
Cancer
High Blood Pressure
High Cholesterol
Thyroid
Multiple Sclerosis
Sleep Apnea
Rosacea
Auto Immune Disease
Psychological
Diabetes
Are You Pregnant
*
Yes
No
Name of Last Eye Doctor
First
Last
Clinic
Date of Last Eye Exam
MM slash DD slash YYYY
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 Contact Lenses?
*
Yes
No
List All Current or Past Eye Diseases, Eye Injuries, or Eye Surgeries
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
ex. Cataract - Mother
ex. Cataract - Mother
ex. Cataract - Mother
Do You Use Tobacco Products?
*
Current
Previous
Never
Do You Drink Alcohol?
*
Socially
Daily
Never
Please check any current eye issues:
*
Amblyopia (lazy eye) / Eye Turn
Burning Eyes
Cataracts
Double Vision
Drooping Eyelid
Dry Eyes
Floaters/Spots
Fluctuating Vision
Foreign Body Sensation
Glaucoma
Glare/Light Sensitivity
Headaches
Itchy Feeling
Infection of Eye/Lid
Loss of Vision-Central
Loss of Vision-Side
Mucus/Discharge
Redness
None
Other
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 your eyes/vision?
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First Choice
Second Choice
Third Choice
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