Patient Vision & Medical History Form

ADVERTISEMENT

Anderson Eyecare
Dr. John E. Anderson
3786 Central Pike, Suite 118
Dr. Terri D. Anderson
Hermitage, TN 37076
“Clearly Focused on You”
Optometrists
(615) 883-9595 (fax 883-9691)
Vision & Medical History
We would like to welcome you back to Anderson Eyecare.
Please take the time to complete the following information.
Emergency Contact _____________________Relation _____________ Emergency Contact Phone #_________________________
Marital Status of Patient:
S
M
Patient Employed:
ingle
arried
Full Time
Part Time
Not Employed
Student
Retired
Current Vision Assistance:
(
Please mark any that you use.)
Medical History:
(Please
at least one box/line.)
Self
Family
No One
Glasses
Reading Glasses
Magnifier
Diabetes
Disp. Contacts
1 Year Contacts
Hard Contacts
High Blood Pressure
High Cholesterol
Patient Vision History:
(
Please mark any you experience.)
Arthritis
Distance Blur
Watery Eyes
Floaters
Glaucoma
Near Blur
Dry Eyes
Flashes of Light
Macular Degeneration
Glare
Itchy Eyes
Blackouts
Eye Disease
Tired Eyes
Burning Eyes
Other
Respiratory Problems
Other
___________________________________________________
Medical History (
):
(Please
or circle one / line.)
Patient Only
___________________________________________________
Currently
Previously
Never
Cataracts
Vision Questions:
(Please circle Yes or No.)
Allergies
Head/Eye Trauma/Surgery
Does sunlight ever cause you to squint?
Y
N
Asthma
Do you operate power tools or do yard work?
Y
N
Pregnant or Nursing
Are there times you would rather not wear glasses?
Y
N
Do your eyes feel tired after extended computer use?
Y
N
Head Aches
Rare
Occasional
Frequent
If you wear glasses or contacts, is there anything you
(circle one)
would like to change about them (other than clarity)?
Y
N
Current Medications (Rx & Over-the-Counter):
___________________________________________________
Name of Medication
Antihistamine - _______________________________
Your Examination Needs Today:
(Please
all that apply.)
Blood Pressure Meds. - ________________________
Thorough Vision & Eye Health Exam (includes glasses Rx)
Diabetes Meds. -______________________________
Limited Exam for Specific Eye Problem
Contact Lens Fitting & Training for New Wearer
Headache Meds. -_____________________________
Contact Lens Evaluation & Renewal of Prescription
Oral Contraceptives - _________________________
Surgery Pre-op or Consultation
Other :
Eye Drops -__________________________________
Your Eyewear/Contacts Needs Today:
(Please
all that apply)
____________________________________________
I would like to order new glasses today.
____________________________________________
I would like to order contacts today.
I do not take prescription or “Over the Counter” meds.
Examination History:
I hereby give my consent to Dr. Anderson to provide
Are you allergic to any medications? ___________________
eyecare services for me and/or my family and to obtain records
Name of your Physician: ____________________________
from my current and/or previous doctors. I also authorize the
Phone #: ____________________________
release of information and payment of vision/medical benefits,
if I choose to use an insurance plan for which the doctors are
Medical Information:
( O P T I O N A L )
providers.
Do you use tobacco products?
No
Occasional
Often
Do you drink alcohol?
No
Occasional
Often
_______________________Date___________
SIGNATURE
History Reviewed by:_______________________
Date Reviewed:___________________________
C:\My Documents\Front Desk Forms\Return Pt Form(2008).doc

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go