Welcome Back To Professional Family Eyecare Patient InformationToday’s Date: MM slash DD slash YYYY Name First Middle Last Sex M F Date of Birth MM slash DD slash YYYY AgeAddress Street Address City State / Province / Region ZIP / Postal Code Home/Daytime PhoneCell PhonePatient’s SSNEmployer (or School)Occupation (or Grade)Email Address Parent’s Name for MinorsName First Last Name First Last What is your preferred method of contact?What is the major purpose of this visit?Current Eyewear and ContactsDo you have any problems with your current contact lenses or glasses?Do you currently wear contacts? Yes No Do you sleep in your contacts? Yes No Are you satisfied with the vision and comfort of your contacts? Yes No How often do you replace your contacts?Eye Health HistoryHave you ever experienced, been diagnosed, or treated for any of the following? Eye Injury Retinal Detachment Glaucoma Diabetes Macular Degeneration Double Vision Burning / Itchiness Cataracts Tearing Retinal Problems Flash of light / Floaters Other Primary Care InformationPrimary Care Doctor: First Last Primary Phone Number:Primary’s Location: Street Address City State / Province / Region ZIP / Postal Code Medical HistoryCURRENT MEDICATIONS (List name of medications including eye drops, vitamins, over the counter and birth control pills): Add RemoveList all allergies (seasonal/medications) Add RemoveHave you ever been diagnosed or treated for the following health problems?Allergies Yes No please specifyArthritis Yes No please specifyBlood/Lymph Yes No please specifyCancer Yes No please specifyTypeCholesterol Yes No please specifyDiabetes (Insipidus/Mellitus) Yes No please specifyDigestive Yes No please specifyEars/Nose/Throat Yes No please specifyEndocrine Yes No please specifyHigh Blood Pressure Yes No please specifyIntegumentary (Skin) Yes No please specifyKidney Yes No please specifyNeurological Yes No please specifyPsychological Yes No please specifyRespiratory Yes No please specifyThyroid (Hyper/Hypo) Yes No please specifyOther Yes No Family Eye/Medical History (Check all that apply)Is there a family history of any of the following: Maternal/Paternal BlindnessMaternal/Paternal Retinal ProblemsMaternal/Paternal GlaucomaMaternal/Paternal Macular DegenerationMaternal/Paternal Corneal ProblemsMaternal/Paternal DiabetesMaternal/Paternal OtherPatient Financial Responsibility I hereby authorize Professional Family Eyecare to apply my vision benefits on my behalf for covered services rendered. I agree to assume responsibility of full payment pending any balance that is not covered by the insurance company.Signed Δ
