Patient Record Form

Patient's Name *
Last Name *
Patient Social Security #
Insured Social Security #
Date of Birth
New Patient
Yes No
Address
City
State
Zip
Daytime Phone *
Cell Phone
Work Phone
E-mail *
Referred By
Family Physician
Employer
Occupation
List of Allergies (Enter one per row)
List of Surgeries (Enter one per row)
Date of Last Eye Exam
Age of Present Glasses
Have You Ever Worn Contacts?
Yes No
Do You Currently Wear Contacts?
Yes No

Family History

(Mother, Father, Grandparents, Siblings)
Inherited Diseases
Are there any inherited diseases such as Diabetes, Blindness, Claucoma, Cataracts, Macular Degeneration, Cancer Thyroid Disease and High Blood Pressure?
Yes No
If yes explain

Review of Medical Systems

Do you currently have any problems in the following areas? If yes, please describe
Eyes (poor vision, eye pain, redness, cataracts, glaucoma)
Yes No
If yes explain
Ear, Nose & Throat (hard of hearing, stuffy nose, earache, cough)
Yes No
If yes explain
Cardiovascular (High Blood Pressure, high pulse)
Yes No
If yes explain
Respiratory (shortness of breath, congestion, asthma)
Yes No
If yes explain
Gastrointestinal (ulcers, hernia)
Yes No
If yes explain
Musculoskeletal (arthritis, swelling, osteoporosis)
Yes No
If yes explain
Skin/Breast (skin cancer, eczema, breast cancer)
Yes No
If yes explain
Neurological (migraines, seizures, headaches)
Yes No
If yes explain
Psychiatric (anxiety, depression, insomnia)
Yes No
If yes explain
Endocrine (Diabetes, thyroid disease)
Yes No
If yes explain
Hematologic (anemia, high cholesterol, bleeding disorder)
Yes No
If yes explain
Allergic/Immunologic (allergies, hives, lupus, swelling)
Yes No
If yes explain

Social History

(For patients 13 and older)
Have you ever had a blood transfusion?
Yes No
Do you use alchohol?
Yes No
If yes, how much?
Do you smoke?
Yes No
If yes, how much?
How many years?
Signature

Typing your name constitutes a signature
You may be asked to sign this form in the office to verify authenticity
Verify *
To Verify, Type: quality