Anthony Wayne Vision Services, Inc

Daniel J. Robinson, O.D.Telephone : 419.878.3937

8245 Farnsworth Road – Suite AFax : 419.878.3947

Waterville, Ohio 43566

Name: ______MI___ Birth Date: ____/___/______Sex: ____ SS# ______-______-______

Race: White Black/African American Asian Hispanic Hawaiian American Indian Ethnicity: Caucasian Hispanic Hawaiian Height ______Weight______Marital Status M S D W E-mail (req)______

Home Address: ______Home Phone: (_____) ______

City/State/Zip ______Cell Phone: (_____)______

Occupation or School: Full or Part Time Work Phone (_____) Grade: ______

Primary Care Physician ______Date of Last Eye Exam (if not here) ______By Dr. ______

Person Responsible for Account (Spouse or Parent) ______Phone (_____)______

Address if different from above: ______

Vision Insurance: ______Health Insurance:______

Insurance policy holder: ______DOB: ____/____/______Relationship to Patient: ______

PRIMARY REASON(S) FOR YOUR EYE EXAMINATION: ______

DO YOU PLAN ON NEW GLASSES AND/OR CONTACTS TODAY: ______

PATIENT HISTORY: Currently have problems/symptoms in the following areas? Circle YES or NO If YES, please explain.

Constitutional (Fevers, Change in Appetite, Fainting, etc.)YESNO ______

Integumentary (Skin, Breast, Lupus, Raynauds, Rashes, etc.)YESNO ______

Head (Ears, Nose, Throat, Headache, etc.)YESNO ______

Respiratory (Lungs, Asthma, Emphysema, COPD, Shortness of breath, etc.)YESNO ______

Cardiovascular (Heart, Blood Pressure, Cholesterol, Chest pain, etc.)YESNO ______

Gastrointestinal (Stomach, Intestines, Ulcer, GERD, Indigestion, etc.)YESNO ______

Endocrine (Diabetes, Thyroid, Crohns, Pituitary, Dizziness, etc.)YESNO ______

Genitourinary (Kidney,Prostate,Bladder,Uterine Cancer, Incontinence, etc.)YESNO ______

Hematolytic (Blood), Lymphatics (Anemia, Leukemia, Fatigue, etc.)YESNO ______

Musculoskeletal (Muscle, Bones, Arthritis, Osteoporosis, Joint Pain, etc.) YESNO ______

Neurologic (Brain, Headache, MS, Parkinsons, Epilepsy, etc.)YESNO ______

Psychiatric(Alzheimers,ADD,Depression,Drug Dependency, Paranoia, etc.)YESNO ______

Immunologic (AIDS, Sarcoid, TB, Sjogrens, Viral Infection, Cough, etc.)YESNO ______

Allergic(Environmental, Animals, Difficulty breathing, etc.)YESNO ______

PATIENT EYE HISTORY:

Cataract, Macular Degeneration, Injury, Surgery, Pain, Lazy EyeYESNO ______

Glaucoma, Diabetic Retinopathy, etc.. ______

Do you smoke?NeverFormer SmokerCurrent Smoker: Light (1-9/day) or Heavy

Do you drink alcohol? None Socially 1-2 drinks/dayAbove average

Do you use narcotics? NoneRecreationalChemical Dependence

FAMILY EYE HISTORY: Blood relatives with any of the following? If YES, explain maternal/paternal relationship

Blindness YESNO ______Cataract YES NO ______

Glaucoma YESNO ______Macular Degeneration YES NO ______

Other Family EYE History ______

MEDICATIONS: If you have a list we can copy, circle COPY OF LIST ATTACHED If no medications, circle NONE

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MEDICATION ALLERGIES: ______

This patient information sheet conforms to the requirements outlined by the Federal
Health Information Technology for Economic and Clinical Health Act - HITECH.

We kindly request that at least 24 hours advance notice be given to cancel your appointment. We cannot guarantee appointments for patients who arrive more than 15 minutes late. Our office is glad to handle your insurance forms as a courtesy to you, however, it is the ultimate responsibility of the patient to verify his/her eligibility and to accept financial responsibility for the account.

I understand and agree to the above conditions: SIGNATURE ______DATE ______