Thank You for Choosing Complete Vision to Care for Your Eye Health and Vision Needs
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 InformationVision 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!