Personal Information

(Circle One) Mr. Mrs. Ms. Dr.

Last Name

First Name MI

E-mail

Address

City State Zip

Home Phone

Work Phone

Cell Phone

Date: / /

Date of Birth / /

Occupation

Employer

Last exam / / Referred by

Primary vision coverage

Emergency Contact Name

Emergency Contact Phone

Relation

Medical Information

Do you have problems with any of these systems? (Please check all that apply)

Gastrointestinal

Ears/Nose/Throat

Cardiovascular

Respiratory

High Blood Pressure

Nervous

Urinary

Skin

Eyes

Endocrine (glands)

Blood/Lymph

Allergic/Immunologic

Headaches

Mental

NONE

Please explain any checked answers

Diabetes? No Yes

Type______

Date of Diagnosis______

Allergies to Medication? No Yes

Type(s)

Reactions

Current Medication(s)

Have you had any operations? No Yes Type When

Other health problems

Name of family doctor Date of last visit

Family History

Do any family members have any of these problems? (Please check all that apply)

High Blood Pressure

Diabetes

Glaucoma

Relation______

Relation______

Relation______

Cataracts

Macular degeneration

Retinal detachment

Relation______

Relation______

Relation______

Personal Eye Information

Do you have any eye conditions or problems? No Yes

If yes, please describe______

Have you had any eye operations? No Yes Type______Date ______

Have you had any eye injury(ies)? No Yes Type______Date ______

Do you have any of the following conditions? (Check all that apply)

Glaucoma

Macular degeneration

Cataracts

Retinal Detachment

Dry Eyes

Blurred Vision

Do you wear glasses?

Contact Lenses?

Type______

(Please turn over to complete the back side)

Eye Care for Your Lifestyle

  • Are you interested in LASIK?YesNo
  • Are you interested in Contact Lenses? Yes No
  • Do you suffer from Dry Eyes?YesNo
  • How much time do you spend on the computer per day?

So that we can get to know you better…What hobbies, sports, or other activities do you enjoy?

______

HIPAA AGREEMENT
INSURANCE ASSIGNMENT AND DISCLAIMER
I acknowledge that I have read a copy of Northpark Optometry Inc.’s Notice of Privacy Practices, available from our office receptionist. (This can also be viewed on our website:
I assign my insurance benefits payable to Northpark Optometry, Inc. I understand that I will receive services and/or materials from Northpark Optometry Inc., and I agree that I am financially responsible for any balance that is not covered by my vision or medical insurance.
Name: Date:
Signature (parent/guardian if under 18 y.o.):

Doctor Use only

Reviewed by______Changes______Date ______

Reviewed by______Changes______Date ______

Reviewed by______Changes______Date ______

Reviewed by______Changes______Date ______