Patient Information Form Page 2
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1
2
3Name:
Age:
/Age
/DOB
Chart:
DOB:
Date:
Referring Dr:
Any past eye problem?
Describe the reason for your visit today:
Family Doctor
Pharmacy/Street Address
o Yes o No
Does your vision limit any activities of daily living (driving, reading, sports, work, etc.)?
Family History
Living Conditions:
Have you been treated for any of
o Single
o Married
the following?
Yes No
(please mark yes or no)
o
o
o Widowed
o Nursing Home
Yes No
Arthritis
(please mark yes or no)
o
o
o
o
AIDS
Blindness
o
o
o
o
Allergies
Cancer
Smoking
(Hay Fever, Skin Rash)
o
o
o
o
o Never smoker
Arthritis
Cataracts
o
o
o
o
o Current every day smoker
Cancer
Diabetes
(including skin cancer)
o
o
o
o
o Current some day smoker
Cardiovascular (Heart, Vessels)
Glaucoma
o
o
o
o
o Heavy tobacco smoker
Cataract
Heart Disease
o
o
o
o
o Light tobacco smoker
Cholesterol (High / Low)
Hypertension
o
o
o
o
o Former smoker
Crossed Eyes
Macular Degeneration
o
o
o
o
Ear/Nose/Throat
Retina Disease
(Sinus, Infection)
o
o
o
o
Endocrine (Diabetes, Thyroid)
Stroke
Hobbies / Activities
o
o
o
o
o Golf
o Hunting / Fishing
Glaucoma
Thyroid Disease
o
o
o Water Sports o Computer Work
High Blood Pressure
o
o
o Tennis
o Needlepoint
Lungs (Asthma/Emphysema)
Alcohol
o
o
o Never
o Reading
o
Retinal Detachment
_________
Other
o
o
o Once a month or less
Stroke
o
o
o 2 to 4 times a month
Tuberculosis (TB)
List any past surgeries (including
o 2 to 3 times a week
any past eye surgeries)
OTHER:__________________________
o 4 or more times a week
o No Past Surgeries
List current Rx & over-the counter medications, including eyedrops
o No Active Medications
List Medication Allergies:
o No Known Drug Allergies
What additional services would you like to learn about? Please check all that apply.
o iLASIK laser vision correction
o Botox Cosmetic
o Brown spots/age spots/freckles
o Computer Eyewear
o Juvederm
o Facial veins / redness / blotchy skin
o Colored Contact Lens
o Facial fine lines/wrinkles
o Laser hair removal
o Drooping brow
o Crow's feet area
o Scar revision
o Drooping eyelid
o Frown lines area
o Body contouring
I authorize the request and use of my prescription medication history from other healthcare providers or third party pharmacy benefit payors
for treatment purposes.
Signature of patient or guardian:
Date:
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