Thank you for choosing Anderson Eye Care, PLLC to care for your eye health and vision needs. We ask that you fill out the health questions below so that we may have a thorough health history.
Today’s Date:______/______/______
Last ______First ______MI ___
Street______
City ______State _____Zip Code______
Home Phone ______
Work Phone ______
Cell Phone ______/ Date of Birth _____/_____/_____ Age ______Sex M F
Social Security Number ______
Marital Status: Single Married
Employer (or School) ______
Occupation (or Grade) ______
Parent/Guardian (under 18 only)______

Email address ______

Insurance Information
Vision Insurance:______
Subscriber’s Name:______
Subscriber’s SSN:______
Subscriber’s Birth Date: / Primary Medical Insurance:______
Subscriber’s Name:______
Subscriber’s SSN:______
Subscriber’s Birth Date:
How will you settle your account today? / ¨  Check / ¨  Cash / ¨  Credit Card
Family Medical/Eye History (check all that apply)
Is there a family (blood-relative) history of any of the following?
¨  Blindness
¨  Cataracts
¨  Corneal disease / ¨  Glaucoma
¨  Lazy eye
¨  Crossed eyes / ¨  Macular Degeneration
¨  Retinal problems
¨  Diabetes / ¨  Liver disease
¨  High Blood Pressure
¨  Heart disease
Patient Medical History
Family Physician______Location______Date of Last Physical______
Current Medications (Rx or Over the Counter) (List medications including eye drops, vitamins & birth control pills)
______
Allergies to Medications: / ¨  No / ¨  Yes Please List:______
Have you ever been diagnosed with or treated for the following?
¨  Allergies
¨  Asthma
¨  Arthritis / ¨  High Cholesterol
¨  Diabetes
¨  Heart Disease / ¨  High Blood Pressure
¨  Hyper-/Hypothyroid
¨  Cancer/______/ ¨  Kidney Disease
¨  Nervous System Problems
¨  Other ______
Patient Eye History
When was your last vision exam?
Have you ever been diagnosed or treated for the following?
¨  Cataracts
¨  Corneal Abrasion
¨  Eye Infection / ¨  Eye Injury
¨  Crossed Eye
¨  Glaucoma / ¨  Iritis / Uveitis
¨  Lazy Eye
¨  Macular Degeneration / ¨  Retinal Detachment
¨  Eye Surgery / Disorders ______
What is the reason for today’s exam? (check all that apply)
¨  Blurry vision at far
¨  Blurry vision up close
¨  New glasses
¨  New contact lenses / ¨  Headaches
¨  Eyestrain
¨  Poor night vision
¨  Double vision / ¨  Redness
¨  Dry / Grittiness
¨  Burning eyes
¨  Itchy / watery eyes / ¨  Sunlight sensitivity
¨  Eye pain
¨  Floaters/spots
¨  other:
Do you….(check all that apply)
¨  Wear glasses?
¨  Wear contact lenses?
What kind? ______
Solution used______
Satisfied with vision and comfort?
¨  No / ¨  Yes
/ ¨  Use a computer? _____hrs/day
¨  Spend time outdoors? ____hrs/week
¨  Have prescription sunglasses?
¨  Have more than one pair of current Rx glasses? / ¨  Have interest in contact lenses that change the color of your eyes?
¨  Want information on Laser Vision Correction?
VERY IMPORTANT! NEW PATIENTS ONLY
Who may we thank for referring you to our office? ______
If not referred, how did you choose our office for your needs?
¨  Another Doctor / ¨  Insurance List / ¨  Phonebook / ¨  Friend/Family / ¨  Sign/Building / ¨  Newspaper / ¨  Other
When you are finished, please return this sheet to the front desk. The doctor and technicians will review your information to customize the exam just for you!