PlazaLaneOptometry

Today's Date

Name

First Last

SSN

How would you like to be addressed?

Birthdate

Address

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

E-mail

Phone (Home)

Phone (Cell)

Phone (Work)

Employment Information

Employer

Occupation

Work Address

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

Vision Insurance Company

Insurance Information

Insurance Responsible Party Spouse/Parent (if minor)

Relationship to Patient

SSN

Address

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

Phone

Vision Insurance Company

Whom may we thank for referring you to us?

Emergency Contact

Phone

List any special interests or hobbies:

Would you like information on: (Check box for Yes)

Refractive surgery (LASIK)
Contact Lenses?
Contact Lenses to eliminate nearsightedness?

Method of payment at time of appointment:

Cash
Check
Mastercard/Visa/American Express

Medical History Questionnaire

Date of Last Medical Exam

Date of Last Eye Exam

Name of Medical Doctor

Doctor's Phone Number

Personal Medical History

Do you have any allergies to medications?*

Yes
No

If yes, please explain:

List any medications you take (including oral contraceptives, aspirin, over-the-counter medications and home remedies):

List all major injuries, surgeries and/or hospitalizations you have had:

Select any of the following that you have had and describe below:

Crossed Eye
Lazy Eye
Drooping Eyelid
Prominent Eye
Glaucoma
Retinal Disease
Cataracts
Eye Infections
Eye Injury

Please describe:

Do you experience symptoms of nausea while reading in a moving car?

Yes
No

Are you pregnant and/or nursing?

Yes
No

Do you wear glasses?

Yes
No

Age of glasses?

Do you currently wear contact lenses?

Yes
No

Type of contact lenses:

Rigid
Soft
Wear Overnight

If you do not wear contact lenses now but have worn them in the past, when did you last wear your lenses?

Family History

Please note any family history (parents, grandparents, siblings and/or children, living or deceased) for the following medical conditions:

If you selected any of the above, please describe the family member's relationship to you:

Do you have visual difficulty when driving?

Yes
No

Review of Systems

Do you currently have any problems in the following areas: (If YES, please explain and list medications below)

Check to indicate YES.

Use this space to describe any of the checked boxes above:

Today's Date

Signature