New Patient Vision & Medical History Form
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1Anderson 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
Name _____________________________________________
Date of Birth ___________________ Marital Status:
S
M
ingle
arried
Street _____________________________________________
Social Security # ____________________ Age_______Sex : M
F
City ___________________ State _______ Zip ____________
Emergency Contact
___________________Relation __________
Phone #
( H )_________________( W ) ______________
Emergency Contact Phone #
___________________________
Employer (or school)__________________________________
Medical Insurance _______________________________________
Occupation (or grade) _______________________F
T
/ P
T
Vision Insurance (if applicable) _____________________________
ull
ime
art
ime
Email Address
_____________________________________
When was your last eye exam? _____________________________
How did you hear about our office? ______________________
Name of the eye doctor? __________________________________
Medical History:
Current Vision Assistance:
(Please
at least one box/line.)
(
Please mark any that you use.)
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
Glaucoma
Distance Blur
Watery Eyes
Floaters
Macular Degeneration
Near Blur
Dry Eyes
Flashes of Light
Eye Disease
Glare
Itchy Eyes
Blackouts
Respiratory Problems
Tired Eyes
Burning Eyes
Other
Other
___________________________________________________
Medical History (
):
(Please
or circle one / line.)
Patient Only
Currently
Previously
Never
___________________________________________________
Cataracts
Allergies
Vision Questions:
(Please circle Yes or No.)
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
(circle one)
If you wear glasses or contacts, is there anything you
would like to change about them (other than clarity)?
Y
N
Current Medications (Rx & Over-the-Counter):
Name of Medication
___________________________________________________
Antihistamines________________________________
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
Headache Meds. -_____________________________
Contact Lens Fitting & Training for New Wearer
Contact Lens Evaluation & Renewal of Prescription
Oral Contraceptives -___________________________
Surgery Pre-op or Consultation
Eye Drops -__________________________________
Other :
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
from my current and/or previous doctors. I also authorize the
Name of your Physician: ____________________________
release of information and payment of vision/medical benefits,
Phone #: ____________________________
if I choose to use an insurance plan for which the doctors are
Medical Information:
providers.
Do you use tobacco products?
No
Occasional
Often
_______________________Date___________
SIGNATURE
Do you drink alcohol?
No
Occasional
Often
C:\My Documents\Front Desk Forms\New Patient Welcome Form (2008).doc
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Parent category: Medical