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

How Did You Find Out About Our Office?*

If you are a Gundersen patient, can we access your 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

Are You Pregnant*

Yes
No

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 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.

Do You Use Tobacco Products?*

Current
Previous
Never

Do You Drink Alcohol?*

Socially
Daily
Never

Please check any current eye issues:*

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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