Burnt Hills Optical
ADVERTISEMENT
1
2
3Burnt Hills Optical
Last Name_______________________ First Name___________________ MI____
Date of Birth: __________
*Family History*
Is there any family medical history of any of the following? (If yes please list the relationship to you)
Cataracts
Yes No _______________
Diabetes
Yes No ___________________
Glaucoma
Yes No _______________
High Blood Pressure
Yes No ___________________
Lazy Eye
Yes No _______________
Retinal Detachment
Yes No ___________________
Macular Degeneration
Yes No _______________
Color Blindness or other Yes No ___________________
*Patient Eye History*
Have you ever been diagnosed or treated for the following?
Do you experience any of the following?
Cataracts
Yes
No
Blurry Vision
Yes
No
Sometimes
Glaucoma
Yes
No
Headaches
Yes
No
Sometimes
Macular Degeneration
Yes
No
Double Vision
Yes
No
Sometimes
Retinal Detachment
Yes
No
Flashes of Light
Yes
No
Sometimes
Lazy eye or Eye turn
Yes
No
Persistent Floaters
Yes
No
Sometimes
Eye Injury
Yes
No
Eye Itching
Yes
No
Sometimes
Eye Surgery
Yes
No
Eye Burning
Yes
No
Sometimes
Eye Tearing
Yes
No
Other: ______________________________________
Have you ever been diagnosed or treated for any of the following conditions?
Explanation of Condition
Endocrine- thyroid, hormones, glands
Yes
No
___________________________________________
Cardiovascular – heart, blood vessels
Yes
No
___________________________________________
High Blood Pressure
Yes
No
___________________________________________
Respiratory- lungs, breathing
Yes
No
___________________________________________
Gastrointestinal- stomach/ intestines
Yes
No
___________________________________________
Genitourinary- genitals, kidneys, bladder
Yes
No
___________________________________________
Musculoskeletal- muscles, joints, arthritis
Yes
No
___________________________________________
Skin or other Integument Condition
Yes
No
___________________________________________
Neurological- migraine, seizures
Yes
No
___________________________________________
Psychiatric
Yes
No
___________________________________________
Ears, Nose, Mouth or Throat
Yes
No
___________________________________________
Hematologic/Lymphatic- anemia, bleeding
Yes
No
___________________________________________
Allergic/ Immunologic
Yes
No
___________________________________________
HIV/AIDS
Yes
No
___________________________________________
Cancer
Yes
No
___________________________________________
Do you have Diabetes?
Yes No What year were you diagnosed? ___Type 1 or 2
What was your last HbA1c? _______
Do you drink alcoholic beverages?
Yes
No
Sometimes
Are you currently Pregnant or Nursing?
Yes
No
Authorization to pay benefits to physician.
I hereby authorize payment of benefits directly to the doctor for services received. I understand that I am
responsible for the balance of fees not paid by the insurance.
Please sign below that you have reviewed all of the information above and it is correct to the best of your
knowledge.
Signature
Date
______________________________________________
_____________________________
Please bring a list of all your current medications to your appointment
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical