Patient Form - ADULT

Date

Name

First Middle Last

DOB:

Female

Male

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell #

Preferred Contact Name & Number:

Marital Status:

Single

Married

Other

Name of Spouse/Partner:

First Last

Were you referred to our office?

Yes

Who Referred You?

Please fill out name, location, & contact information of the referral source.

Name of professional who referred you:

Address of professional who referred you:

Street Address City ZIP Code

Phone

Fax

Do we have permission to communicate findings with referral source?

Yes

If not referred, how did you hear about us?

Is your condition the result of an accident or injury?

Explain type of injury/accident, and how received:

Date of injury:

is it work related?

Name of Auto or Workman's Comp Carrier:

Address

Street Address City State / Province / Region ZIP / Postal Code

Adjuster Name:

First Last

Phone

Claim#

ADULT EYE HEALTH HISTORY

When was your last eye exam?

Where:

Who is your Primary Care Physician?

Do you have any MEDICATION ALLERGIES?

Yes

so to what?

Please list all MEDICATIONS YOU CURRENTLY USE (including over the counter, eye drops and supplements):

List all EYE SURGERIES or INJURIES:

Have you been diagnosed with any of the following EYE CONDITIONS? (Check all that apply)

Other Eye Conditions:

Check any of the following symptoms you experience:

Other vision related symptoms:

VISION HISTORY:

What is your primary vision correction?

Glasses

Contacts

Neither

Have you ever worn contact lenses

Yes

Are you interested in contact lenses

Yes

please bring your current prescription information with you!

Are your contact lenses comfortable and working well for you

Yes

Do you have additional glasses (back up, reading, computer, sun, music, sports, etc.)

Yes

What is your primary occupation

How many hours per day do you work on a computer

(Reading & Computer Checklist)

Please answer the following questions about how your eyes feel when reading or doing close work.

Do your eyes feel tired when reading or doing close work

Do you have headaches when reading or doing close work

Do you lose concentration when reading or doing close work

Do you have trouble remembering what you have read

Please answer the following questions about how your eyes feel when reading or doing close work.

Do you have double vision when reading or doing close work

Do you see the words move, jump, and swim or appear to float on the page when reading or doing close work

Do you feel like you read slowly

Do your eyes ever hurt when reading or doing close work

Do you feel a "pulling" feeling around your eyes when reading or doing close work

Do you notice the words blurring or coming in and out of focus when reading or doing close work

Do you lose your place when reading or doing close work

Do you have to reread the same line or words when reading

In addition: (Check all that apply):

Tendency to close or cover one eye

Confuse similar looking words

Poor reading comprehension

Poor visual-motor (eye, hand, foot) coordination

Difficulty tracking moving objects, balls, etc.

Misalignment of digits or columns of numbers

Comprehension decreases over time

Does not visualize

Difficulty completing assignments in the time allotted

List your hobbies or other activities:

Review of Systems: Do you currently, or have you ever had, any problems in the following areas:

1. Eyes:

Itching

Yes

Diplopia

Yes

Burning

Yes

Mattering

Yes

Loss of Vision

Yes

Red

Yes

Photophobia

Yes

Floaters

Yes

Loss of Sharpness

Yes

Flashes

Yes

Tearing

Yes

Other

2. Constitutional

Developmental Disorders

Yes

Cancer

Yes

Fatigue Syndrome

Yes

Other

3. Ear, Nose, Mout

Sinusitis

Yes

Dry Mouth

Yes

Hearing Loss

Yes

Laryngitis

Yes

Other

4. Neurological:

Epilepsy

Yes

Multiple Seizures

Yes

Tumor

Yes

Cerebral Palsy

Yes

troke/CVA

Yes

Migraine

Yes

Parkinson's d

Yes

Other

5. Psychiatric:

Depression

Yes

Bipolar

Yes

Anxiety

Yes

Attention Deficit

Yes

Other

6. Vascular/Cardiovascular Vascular Disease:

Stroke

Yes

Heart Disease

Yes

High Blood Pressure

Yes

Congestive Heart Failure

Yes

Other

7. Respiratory:

Cigarette Smoker

Yes

Bronchitis

Yes

COPD

Yes

Emphysema

Yes

Asthma

Yes

Sleep Apnea

Yes

Other

8. Gastrointestinal:

Celiac Disease

Yes

Crohn's Disease

Yes

Ulcer

Yes

Colitis

Yes

Acid Reflux

Yes

Other

9. Genitourinary:

Kidney Disease

Yes

STD - Herpetic/Chlamydia

Yes

Prostate Disease/Cancer

Yes

Pregnant/Nursing

Yes

Other

10. Musculoskeletal:

Arthritis

Yes

Ankylosing Spondylitis

Yes

Fibromyalgia

Yes

Muscular Dystrophy

Yes

Osteoarthritis

Yes

Gout

Yes

Other

11. ntegumentary:

Herpes Simplex/Col

Yes

Herpes Zoster/Shingles

Yes

Rosacea

Yes

Psorias

Yes

Eczema

Yes

Other

12. Endocrine:

Diabetes Type I

Yes

Diabetes Type II

Yes

Thyroid Dysfunction

Yes

Hormonal Dysfunction

Yes

Other

13. Hematologic/Lymphatic:

Anemia

Yes

Ulcer

Yes

High Cholesterol

Yes

Other

14. Hematologic/Lymphatic:

Environmental Allergies

Yes

to what

Lupus

Yes

Rheumatoid Arthritis

Yes

to what

Drug Allergies

Yes

If you answered yes to any of the above, or have a condition not listed, please explain:

List any other conditions (such as Autism, Down syndrome, ADD, ADHD, Speech Impaired, etc.

Do you use any of the following?

Alcohol

Tobacco

Recreational Drugs

Frequency:

FAMILY HISTORY:

Is there a history of any of the following conditions in your family?

Glaucoma

Rheumatoid Arthritis

Diabetes

Retinal Disease

Retinal Detachment

Crossed or Wandering Eye

Macular Degeneration

Albinism

Amblyopia/Lazy Eye

Other Family History of Eye Conditions?

Adult Patient Form

Patient Form - ADULT

Who Referred You?

ADULT EYE HEALTH HISTORY

VISION HISTORY:

(Reading & Computer Checklist)

Please answer the following questions about how your eyes feel when reading or doing close work.

Review of Systems: Do you currently, or have you ever had, any problems in the following areas:

FAMILY HISTORY:

Visual Symptoms Treatment Center