Welcome Form Name* First Last Gender*MaleFemalePlease address me asIf MinorName of parent/guardian First Last Relationship:Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Business PhoneCell PhoneEmail Date of Birth* Date Format: MM slash DD slash YYYY Age*Social Security #*Occupation/School GradeHow did you hear about our office?Insurance providerYellow pagesWebsite/InternetWalked/drove byAnother patientIf another patient, nameYear of Last Eye Exam*Drivers License #StateExpiration DateTo better understand your visual requirements, please check off any of the following sports/activities/work environments that you often engage in Soccer Football Baseball Basketball Racquetball Tennis Skiing Golf Fishing Boating Swimming Hunting Cycling Sewing Needlework Fumes/Chemicals Ocular hazards at work Other If other, please specify*Computer screen (hrs/day)*What is the main reason for your visit today?Please check responses that apply. Blurred distance vision Blurred near vision Headaches New Eyeglasses New Contact Lenses Eyestrain Red/Irritated eyes Other If other, please specify*Please list all medications that you are presently taking, including OTC Do you now wear eyeglasses?*YesNoAre you interested in contact lenses?YesNoDo you wear contact lenses?*NoNowIn PastPlease mark the following if they apply to you or a family member.(including grandparents)High Blood Pressure* No Self Family Member Relative that has conditon*If self, list approximate year of diagnosis*If self, control of condition*GoodFairPoorDiabetes* No Self Family Member Relative that has conditon*If self, list approximate year of diagnosis*If self, control of condition*GoodFairPoorGlaucoma* No Self Family Member Relative that has conditon*If self, list approximate year of diagnosis*If self, control of condition*GoodFairPoorCataracts* No Self Family Member Relative that has conditon*If self, list approximate year of diagnosis*If self, control of condition*GoodFairPoorHeart Disease* No Self Family Member Relative that has conditon*If self, list approximate year of diagnosis*If self, control of condition*GoodFairPoorHIV/AIDS* No Self Family Member Relative that has conditon*If self, list approximate year of diagnosis*If self, control of condition*GoodFairPoorTurned Eye* No Self Family Member Relative that has conditon*If self, list approximate year of diagnosis*If self, control of condition*GoodFairPoorLazy Eye* No Self Family Member Relative that has conditon*If self, list approximate year of diagnosis*If self, control of condition*GoodFairPoorMacular Degeneration* No Self Family Member Relative that has conditon*If self, list approximate year of diagnosis*If self, control of condition*GoodFairPoorPlease mark the following if they apply to you High cholesterol Hypoglycemia Itching eyes Flashes/sparks of light Decreased night vision Arthritis Airborne allergies Burning eyes Eye infection Double vision Thyroid problems Sinus problems Dry eyes Eye disease Pain in eyes Kidney problems Watery eyes Floaters Eye injury Drug sensitivity Headaches/Migraines If Headaches/Migraines:Location in head?*How often?*Severity*Have you had eye surgery?*YesNoIf yes, please specify*When?*Do you smoke?*YesNoHow many packs per day?*Do you drink?*YesNoAre your contact lenses soft or rigid gas permeable?*SoftRigid gas permeableDo you sleep in your contact lenses?*YesNoIf yes, how many nights before removing them?*If not, how many hours per day do you wear them?*How old is your present pair of contact lenses*If your lenses are disposable, how often do you discard them?Do you know the brand name of your contact lenses?Power (strengths) of your lenses in the right eye:Power (strengths) of your lenses in the left eye:What brand of solutions do you use?*Optifree ExpressRenuCompleteSolocareAOseptClearCareGeneric Multi-purposeBostonOptimumBarnes-Hind**Professional fees must be paid for at the time services are rendered. Contact lenses and eyewear require deposits**
