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​                                   Mr.     Miss    Mrs.    Ms.
Name    ________________________________________________________________________________________
                First                                       MI                                  Last                                                               Nickname
Address: _______________________________________________________________________________________

City:__________________________________State ____________________________ Zip ______________
Date of Birth: ____________________________ SS # (last 4 digits)_______________  

Phone:  Home____________________________ Cell: _____________________________Text OK? __________
Circle One:   Single    Married    Widow    Divorce
Email:____________________________________________________

Occupation: ________________________________Employer: _______________________________________

Spouse Name: ________________________ Parent(s) Name if under 18 _________________________________
-Are you Diabetic?   Yes      No
-Are you interested in wearing Contact Lenses:    Yes         No
-Are you interested in Lasik?:      Yes           No
Are you on Hospice Care?      Yes No
-INSURANCE INFORMATION:
-Vision Insurance Co: ____________________________________  ID # _______________________________

Name of Insured:_______________________________Date of Birth______________ 
  SS# _____________________________________________________

​-Medical Insurance Co: __________________________________  ID #   _______________________________

​Name of Insured: ______________________________ Date of Birth _____________
​   SS#______________________________________________________
-Today’s Visit: Please Mark One:
____________  I prefer dilation today (included in the exam)
____________  I prefer Optomap Digital Retinal Imaging (Additional Charge-see info at front desk)
 
-I authorize the release of all medical or other information needed to provide a complete visual
                Examination and/or process the insurance claim.
-I understand that I am financially responsible for all charges which may or may not be paid by the
                Insurance company.
***PAYMENT or Co-Pay is DUE AT THE TIME SERVICES ARE RENDERED***

Signed_______________________________________________  Date  _______________________________


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​--PATIENT HISTORY--
Name:__________________________________________________________   DOB: _____ / _____ / _____
                                 (FIRST)                                   (MI)                                                  (LAST)
Primary Care Physician: _____________________________________________________________________________________
Medications: (If you have a list, please provide to check-in desk)___________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________
List Current Medical Illnesses (i.e. hypertension, diabetes, depression, etc.) ________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________
Eye Medications: _______________________________________________________________________________________________________________________________________________________________________________
Are you on any blood thinners such as aspirin?      YES / NO     Please list: _______________________________________________________________________________________________________________________________________________________________________________
Drug Allergies (if yes, please list):
​_______________________________________________________________________________
​Prior Surgeries, include dates (especially those pertaining to EYES, CARDIOVASCULAR or NERVOUS SYSTEM):
________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________
SOCIAL HISTORY
Pregnant:           YES / NO / Not applicable
Alcohol intake:            YES / NO            Daily / Frequently / Occasionally / Rarely / Never
Tobacco / Vapor Use:      Current / Former / Never           Cigars / Cigarettes / Chewing tobacco / Vape
FAMILY HISTORY
For any YES answers please provide the relationship of the family member
Glaucoma              YES / NO                mother / father / aunt / uncle / brother / sister / cousin / grandmother / grandfather
Cataracts               YES / NO                mother / father / aunt / uncle / brother / sister / cousin / grandmother / grandfather
Retinal Detachment  YES / NO            mother / father / aunt / uncle / brother / sister / cousin / grandmother / grandfather
Macular Degeneration  YES / NO          mother / father / aunt / uncle / brother / sister / cousin / grandmother / grandfather
Diabetes                       YES / NO                mother / father / aunt / uncle / brother / sister / cousin / grandmother / grandfather
High Blood Pressure  YES / NO              mother / father / aunt / uncle / brother / sister / cousin / grandmother / grandfather
Cancer                   YES / NO                mother / father / aunt / uncle / brother / sister / cousin / grandmother / grandfather