Patient Information Patient Information ---Dr.Mr.Mrs.Ms.MissRev. AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Gender: MaleFemale Marital Status: SingleMarriedDivorcedSeparatedWidowed Spouse/Parental Contact (If college student please include) AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Insurance Do you have insurance? YesNo Referral How did you decide to come to our practice? ReferralReturning PatientInsurancePhone BookLocationInternetOther Have other family members been seen in this office by our doctors?: YesNo Medical History Are you under care of a physician now? YesNo Are you pregnant? YesNo Are you nursing? YesNo Vision History NoneGlassesContactsBoth Glasses Do your current glasses have bifocals? YesNo Do you always wear your glasses? YesNo Do you have prescription sunglasses? YesNo Contacts Are you interested in contact lens? YesNo If you wear contacts, are you interested in hearing about new lens technology? YesNo Do you currently or have ever had any problems in the following areas? Blurred vision YesNo Burning YesNo Night driving YesNo Distorted vision/halos YesNo Double vision YesNo Dryness YesNo Excess tearing/watering YesNo Eye pain/soreness YesNo Chronic eye/lid infection YesNo Flashes/floaters in vision YesNo Foreign body sensation YesNo Glare/light sensitivity YesNo Head/eye injuries YesNo Illness that affected eyes YesNo Itching YesNo Loss of side vision YesNo Mucus discharge YesNo Redness YesNo Sandy/gritty feeling YesNo Styes/chalazion YesNo Tired eyes YesNo Do you currently suffer from headaches?: YesNo Headache severity: MildSharpSevereMigraine Time of day headaches occur? AMPMBoth How frequent are the headaches? DailyWeeklyMonthly Where are the headaches generally located? TopFrontBackRight SideLeft Side Do the headaches include visual disturbance? YesNo Review of Systems Do you currently or have ever had any problems in the following areas? Cardiovascular Chest Pain YesNo High Blood Pressure YesNo Low Blood Pressure YesNo Rapid Heartbeat YesNo Irregular Heartbeat YesNo Swollen Ankles YesNo Vascular Disease YesNo High Cholesterol YesNo Psychiatric Depression YesNo Insomnia YesNo ADD/ADHD YesNo Anxiety YesNo Alzheimers YesNo Neurological Dizzy Spells YesNo Head Injury YesNo Headaches YesNo Migraines YesNo Seizures YesNo Stroke YesNo Epilepsy YesNo Parkinson's Disease YesNo Bones/Joints/Muscles Joint Pain YesNo Muscle Pain YesNo Arthritis YesNo Rheumatoid Arthritis YesNo Gastrointestinal Crohn's Disease YesNo Heartburn YesNo Ulcer YesNo Acid Reflex Syndrome YesNo Respiratory Asthma YesNo Chronic Bronchitis YesNo Emphysema YesNo Persistent Cough YesNo Pneumonia YesNo Tuberculosis/TB YesNo Endocrine Diabetes/Blood Sugar YesNo Treatment: DietOralInsulin Thyroid/Other Gland YesNo Social History Do you use tobacco products? YesNo Do you use alcohol? YesNo Do you use illegal drugs? YesNo Ears, Nose, Mouth, Throat Allergies/HayFever YesNo Chronic Cough YesNo Dry Throat/Mouth YesNo Sinus Congestion YesNo Hearing Loss YesNo Lymphatic/Hematologic Anemia YesNo Blood Clots YesNo Bleeding Problems YesNo Cancer YesNo Integumentary (skin) Acne YesNo Dry Skin YesNo Psoriasis YesNo Rosacea YesNo Lupus YesNo Genitourinary Bladder Infection YesNo Kidney Stones YesNo Menopause YesNo Prostate Disorder YesNo Please check if you have ever been exposed to or infected with: N/AGonorrheaHepatitisSyphilisHIV Allergies Food Allergies YesNo Drug Allergies YesNo Environmental Allergies YesNo Family History Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions: ADD/ADHD YesNo Arthritis YesNo Blindness YesNo Allergies YesNo Cataracts YesNo Cancer YesNo Strabismus YesNo Diabetes YesNo Amblyopia YesNo Heart Disease YesNo Dyslexia YesNo Blood Pressure YesNo Glaucoma YesNo Kidney Disease YesNo Macular Degeneration YesNo Lupus YesNo Retinal Detachment YesNo Thyroid YesNo Vision Therapy Have any of the following traits been noted? (Check the box if applies) N/AHolding reading too closeReversing when writing ('b' for 'd')Poor general coordinationPoor posture when readingSquintingReading below grade levelHead close to paper when writing/drawingTransposing letter/numbers ('12' for '21')Capable of doing betterLosing place when readingUsing finger to maintain placeDifficulty copying from the chalkboardTilting head when readingOmitting mall wordsClose or cover one eye while readingVision blur while readingShort attention spanMove lips on silent readingDifficulty in schoolPoor handwritingEyes tired after readingReverse when reading ('was' for 'saw')Bumping into objectsFind reading a chore PLEASE NOTE: Insurance may cover none or only part of your fees. If we do not accept direct payment from your insurance plan, you will need to pay our office at the time of service and submit your receipt for reimbursement from your insurance company. If your insurance does not pay as expected, you are ultimately responsible for all charges, including copays and deductibles. We cannot be responsible if you are not eligible for benefits. We will be happy to assist you with your claims. Please give any forms to the receptionist.