The Eye Works – Med Questionaire – Patient Registration Forms

Welcome to The Eye Works Optometry - Dr. Craig Sultan

Name

First Last

Address

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

Phone (Home)

Phone (Work)

Phone (Cell)

Email

Date Of Birth

Occupation

Parent / Guardian

Marital Status: S/M/D/W

Name of Vision Insurance

Major Medical Ins.

Subscriber Name

Subscriber DOB

SS#

What is the best way to contact you?

Phone
E-mail
Text Message
Mail
Pigeon
Smoke Signals

How did you hear about our office?

Major reason(s) for today's visit (Select all that apply)

Glasses
Contacts
Laser Correction
Eye Health
General Wellness
Other (Please explain)

Last vision exam & location

Currently wear contact lenses? Yes or no. If yes, any concerns?

Interested in the newest in contacts?

Number of hours per day on computer or electronic devices

Number of hours per day spent outdoors

Do you have prescription sunglasses?

Do you drive at night?

Interested in laser correction?

Do you experience, or have you had any of the following? With current correction

Personal Medical History (Click all that apply)

Family History

Diabetes - Who?

Glaucoma

Macular degeneration

High blood pressure

Blindness

Stroke

List all current meds

Last med exam

Physician's name

Additional comments

HIPPA PRIVACY NOTICE: This office's privacy practices are in accord with HIPPA regulations. You may obtain a copy of our privacy practice at any time.Your signature here indicates that you have been advised of the availability of this information.

Signature

Date