DATE______

WELCOME TO OUR OFFICE

Last Name______First Name______M.I___ Age___ Sex___

Address______Apt.____City______State______Zip______

Cell #______Home #______E-mail______

Occupation______Work#______Employer______Employer Address______Marital Status_____ D.O.B______

How did you hear about our office? (Please Circle) Friend, Family, Insurance, Newspaper, Magazine, Walk/ Drive by, Coupon, Doctor:______Other:______

Family Physician:______

Spousal Information: Name______Occupation:______Work#______Employer:______

Eye History: Do you wear (circle): None Glasses Contact Lenses Both

PLEASE CIRCLE ANY CONDITION YOU HAVE PRESENTLY OR HAVE HAD IN THE PAST:

Dry Eyes Glaucoma Cataracts Macular Degeneration Retinal Detachment Keratoconus Other______

PLEASE CIRCLE ANY CONDITION YOUR FAMILY MEMBER OR BLOOD RELATIVE HAVE PRESENTLY OR HAVE HAD IN THE PAST

Cataracts Dry Eyes Glaucoma Keratoconus Macular Degeneration

Retinal Detachment Other______

General Health History: Is this your first eye exam? Yes / No Are you Pregnant? Yes/ No/ N/A

Please circle any condition you have presently or have had in the past: (Circle Condition)

No known medical condition___

HighBloodPressure HeartProblem Arthritis LungProblems Stroke ThyroidProblems Diabetes: Yes/No If Yes Specify Type: ______LDL Ulcers Cancer Others:______

Circle Conditions your family/blood relative have presently or have had in the past: (Circle Condition)

No known medical condition___

HighBloodPressure HeartProblem Arthritis LungProblems Stroke ThyroidProblems Diabetes: Yes/No If Yes Specify Type: ______LDL Ulcers Cancer Others:______

Annual colorectal cancer screenings___ Received flu vaccine___ Received Pneumococcal Vaccine___ Receiving annual mammogram___ High-risk for cardiac events on aspirin prophylaxis___ Falls: Risk Assessment___ Counseling for Nutrition/Diet___ Counseling for Physical Activity___

Reviews of systems: (Circle Condition)

Seasonal Allergies Hay Fever Chest Pain Congestive Heart Failure Irregular Rhythm Fever Weight Loss Rash Skin Disease Vomiting Ulcers Diarrhea Bloody Stools Genital Ulcers Discharge Kidney Stones Blood in Urine Sinus Problems Post Nasal Drip Runny Nose Dry Mouth Hearing Loss Headache Migraines Paralysis Fever Joint Ache Cough Bronchitis Shortness of Breath Asthma Emphysema COPD

SOCIAL HISTORY:

Smoker: Yes/No

Smoke (cigarettes, cigars, pipe) _____#per day/___Years Recreational Drugs Y/N

Alcohol (beer, wine, liquor) _____ socially ____Daily ____Never

Medications: Yes/No Include Name/Dosage (Mg)/ How many times daily______

Do you Have any Allergies to any Medications?______

Sx/ Procedures:

___No Surgeries

___Ocular Surgery Type/Date/Physician______

Type/Date/Physician______

___Other Surgery Type/Date/Physician______

Type/Date/Physician______

I understand and agree that (regardless of my insurance status), I am ultimately responsible for the balance of my account for any professional services rendered. I understand if there should be any legal action required to obtain any balances I will be responsible for all legal fees.

I authorize to release any information and records to any insurance company, adjuster, attorney or insurance commissioner. I authorize and request payment of medical benefits, including Medicare benefits, be made on my behalf to the practice for professional services and treatment rendered. If your insurance requires a referral, it is your responsibility to obtain the referral for your appointment. If not, you will be billed for the visit.

Lifetime Signature on File______Date______