PERSONAL AND MEDICAL BACKGROUND INFORMATION Patient Name(Required) First Last Date(Required) MM slash DD slash YYYY Occupation Hobbies Name of:Name of spouse If patient is a child: Father Mother Please list the names and ages of other children (under 18) Add Remove1. The main reason(s) for today’s visit is / are: 2. When was your last Eye Examination? Last General Physical? 3. MEDICAL HISTORY: Please list ALL …a. Medical Problems (Diabetes, High Blood Pressure, Kidney Disease, Cancer, etc.)(Required) Add Removeb. Medications that you are taking, and what you are taking them for:(Required) Add Remove4.The Optomap Retinal Examination is prescribed in our office to evaluate the health of your retina (back part of the eye). The advantages to you are: Fast (less than 1 second per eye) No blurred vision afterwards and no need for Dilation in most cases. You will be able to see the back part of your own eye, and the doctor will explain the findings. This is now part of your permanent record, so we can then compare the retina from year to year. This new technology is a part of our standard of care. The fee for this test is $45.00. This test is not covered by any medical insurance. I choose to have this test(Required) Yes No 5. The Comprehensive Examination addresses eye health and eyeglass prescriptions. 6. Contact Lens Examination:There are 3 levels; standard, complex, and custom.The fee for this service is separate from the comprehensive examination.7. A Vision Plan examination is a routine examination for healthy eyes. Medical Insurance is for MEDICAL issues such as Diabetes, Brain Injury, Strabismus (an eye turn), Amblyopia (lazy eye). EYE or HEAD injuries, illnesses, or surgeries? Yes No Headaches? Yes No Is there a family history of any severe eye problems or health problems? Yes No Explain Do you currently wear [ ] Eyeglasses? [ ] Contact Lenses Yes No Are you interested inGetting Eyeglasses today? Yes No Getting Contact Lenses for full time, part time, or for occasional wear, such as sports or social events? Yes No Learning about a Non-Surgical method to correct your vision? Yes No Learning about ways to control and prevent your child from becoming more nearsighted each year? Yes No Is your child having school-related problems or difficulty reading? Yes No Are you having vision problems after LASIK or PRK? Yes No Are you having vision problems after a Brain Injury? Stroke, Crash, Fall, etc. Yes No
Appointment times may vary so call us for availability.