Precision Eyecare

Name*

First Middle Initial Last

Nickname/Preferred Name

Parent/Guardian Name

Address*

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

Home Phone

Cell Phone

Date of Birth

SSN

Email

Occupation

Employer

Work Phone

Emergency Contact Name

Emergency Contact Phone

Name of Family Doctor

Date of Last Visit

Date of Last Eye Exam

Preferred Language

English
Spanish

Ethnicity

Hispanic/Latino
NOT Hispanic/Latino

Race

White
American Indian
Asian
African American
Pacific Islander
Native Alaskan

Medical Information

Do you have problems with any of the below systems? Check any that apply.

Please explain any of the above selected:

Height

Weight

Allergies to Medications?

Yes
No

Which medications?

Medications currently taken

Are you currently pregnant or breast feeding?

Yes
No

Do you currently or have you ever smoked?

Yes
No

Drink alcohol?

Yes
No

Have a history of STD?

Yes
No

List any operations you have had:

Family History

Do you have family history of the following? If yes, please check and indicate relation below.

High Blood Pressure
Diabetes
Glaucoma
Macular Degeneration
Cataracts
Retinal Detachment

Relation?

Personal Eye Information

Do you have any eye conditions or problems?

Yes
No

What kind?

Have you had any eye operations?

Yes
No

Type of operation and date of procedure?

Have you had an eye injury?

Yes
No

Kind of injury and date?

Do you have glaucoma?

Yes
No

Do you have Macular degeneration?

Yes
No

Do you have cataracts?

Yes
No

Do you have retinal detachment?

Yes
No

Do you have dry eyes?

Yes
No

Do you wear glasses?

Yes
No

Do you wear contact lenses?

Yes
No

Additional Information:

Signature

Date