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Welcome to Walgreens Optical
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2017-07-06T01:14:21+00:00
Welcome to Walgreens Optical
Today's Date:
Date Format: MM slash DD slash YYYY
Preferred Title:
Mr.
Mrs.
Miss
Ms.
Dr.
Name:
First
Middle Initial
Last
Suffix
Gender M/F:
Date of Birth:
MM
DD
YYYY
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Email
Phone
Preferred Method of Communication:
Email
Text
Phone
Emergency Contact Name
First
Last
Emergency Contact Phone
Relation
Insurance Information
Name of Insurance
Member ID / Policy #
Group #
Primary Insured Name:
First
Last
Primary Insured DOB:
Date Format: MM slash DD slash YYYY
Last 4 of SSN for Primary Insured:
Please list any medications you are taking:
Please list any allergies:
Medical History
The following questions ask about you and your family's medical history. If applicable, please select either you or your family from the options below.
Do you or a family member have a history of the following eye problems?
Self
Family
Blindness
Cataracts
Corneal Problems
Diabetic Retinopathy
Dry Eye
Eye Allergy
Eye Injury
Floaters / Spots / Light Flashes
Frequent Eye Infections / Styes
Glaucoma
Iritis / Uveitis
Lazy/Crossed Eye
Macular Degeneration
Retinal Detachment/Tear/
Disease
Other (provide description):
Do you or a family member have a history of the following eye surgeries?
Self
Family
Cataract
Corneal Transplant
Eye Muscle Surgery
Glaucoma Laser / Surgery
Lasik / PRK / RK Incisions
Retinal Laser / Surgery / Injections
Yag (Laser After Cataract)
Other (provide description):
Do you currently...
*
Use Tobacco?
Use Alcohol?
Use Drugs Recreationally?
Have an STD?
Please check all that apply.
Do you have a history of the following medical issues?
Asthma
Blood Pressure Problems
Cancer
Cholesterol Problems
Depression
Diabetes or High Blood Sugar
Emphysema
Heart Problems
Kidney Disease
Liver Disease
Osteoperosis
Seizures
Strokes
Thyroid Problems
Surgeries
Other
Check all that apply
Do you have any problems with any of the below systems?
Constitutional (e.g. Fever, Chills, Weight Change)
Ears / Nose / Throat / Mouth (e.g. Hearing, Discharge, Dryness)
Cardiovascular (e.g. Chest Pain, Palpitations, Labored Breathing)
Respiratory (e.g. Cough, Sputum, Wheezing, Shortness of Breath)
Gastrointestinal (e.g. Heartburn, Nausea, Constipation/Diarrhea)
Genitourinary (e.g. Burning, Pain, Sexual Function, Nocturia)
Musculoskeletal (e.g. Muscle/Joint Pain, Stiffness, Swelling)
Integumentary (e.g. Moles, Non-healing Lesions, Color Changes)
Neurological (e.g. Dizziness, Fainting, Seizures, Weakness)
Psychiatric (e.g. Nervousness, Depression, Memory Loss, Stress)
Endocrine (e.g. Heat/Cold Intolerance, Frequent Urination, Thirst)
Hematologic / Lymphatic (e.g. Bruising, Bleeding, Anemia)
Allergy / Immunologic (e.g. Hives, Eczema, Rash, Lumps)
Check all that apply
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