Welcome to MacArthur Eyecare!

Please fill out this form to the best of your knowledge.

Patient Information
Name : Last:______First:______M.I._____
Address:Street: ______Apt #: ______
City: ______State: _____ Zip Code: ______
Cell Phone: (_____)_____-______Home Phone: (_____)_____-______Occupation: ______
Email ______May we send you emails? O YES O NO
Whom may we thank for referring you? ______Patient’s Date of Birth ____/_____/______
Parent/Guardian Name if under 18 years of age: ______
Medical & Ocular History
Last Medical Exam ______Last Eye Examination ______
Primary Care Physician ______Last Eye Doctor ______
Do you wear:
Glasses O YES O NO Type of glasses: O Single Vision O Progressive/Bifocal
Contacts Lenses O YES O NO Brand of Contacts: ______
Please check all that applies:
Medical Yourself Ocular Yourself Family
Healthy, no medical conditionsOBlurry at distance (w/ glasses/cls)O
DiabetesOBlurry at near (w/ glasses/cls)O
High Blood PressureOHeadache/ Eye StrainO
Heart ConditionsODry EyesO
Asthma / Respiratory Conditions OWatery EyesO
Sinus ProblemsOItchy EyesO
ArthritisOSensitivity to lightO
CancerOFloaters/SpotsO
Thyroid ConditionODouble VisionO
Anemia OEye InjuryO
SeizuresOEye SurgeryO
Other health conditions: ______Lazy Eye O O
List ALL surgeries and year performed:Retinal detachmentOO
______GlaucomaOO
______CataractsOO
Do you use any tobacco products? O YES O NOMacular DegenerationOO
Do you drink alcohol? O YES O NOOther Eye Conditions O O
Have you ever been infected / exposed to: O HIV O AIDS O Herpes O Hepatitis O Syphilis O Gonorrhea O Other ______O NONE
Please list all MEDICATIONS (including birth control, vitamins, over the counter medicines, home remedies and eye drops)
______
Please list any ALLERGIES ( ex: seasonal, drugs, latex, etc...) ______
If applicable, are you pregnant/nursing? O YES O NO If yes, how many weeks along are you? ______

An office visit to recheck the prescription will be provided at no charge within 60 days of the initial exam. Re-check visits after 60 days will be charged a refraction fee ($45). Patient Initials ______