ADULT PATIENT FORM. Full Name: Preferred name: Date of Birth: SSN: Address: Suite/Apt#: City: State: Zip: Phone (home): Phone (cell): Phone (work):

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1 ADULT PATIENT FORM GENERAL INFORMATION Full Name: Preferred name: Date of Birth: SSN: Sex: Male Female Marital Status: Single Married Separated Divorced Widowed Address: Suite/Apt#: City: State: Zip: Phone (home): Phone (cell): Phone (work): Preferred Contact: Phone (home) Phone (cell) Phone (work) Employer: Current Occupation: Emergency Contact: Relationship: Phone: Reason for today's visit: PRIMARY CONCERNS TODAY (or over the last week) (Check all that Apply) Allergies Glare/Sensitivity to Light Blurred Distance Foreign Body Sensation Blurred Near Headache Burning/Stinging Itching Discharge Loss of Vision Double Vision Loss of Side Vision Dryness Pain/Discomfort Eye Strain/Fatigue Redness Floaters/Spots Scratchy/Gritty Sensation Flashes Watering/Tearing Page 1 of 6

2 GLASSES Do you wear glasses? Yes If Yes, for? Near Distance Both Type: Single Vision Progressive Bifocals Trifocals Any Problems? Do you have backup glasses? Yes Do you wear sunglasses? Yes Do you have backup sunglasses? Yes CONTACTS Do you wear contacts? Yes If yes, type of contacts? Full Time Daily Wear Gas Permeable Occasional Extended Wear Bifocal/Progressive Rarely Soft Toric Colored Any Problems? What cleaning solution do you use? Average wear time? hours. How often are they replaced? How old is your current pair? OCULAR HISTORY Previous Eye Doctor: Last Exam: Self Family Who? Amblyopia (Lazy eye) Blindness Cataract(s) Color Deficiency Glaucoma Macular Degeneration Ptosis (Drooping Lid) Retinal Detachment Retinal Tear Strabismus (eye turn) Other History of Eye Surgeries (LASIK, PRK, cataract, other): _ History of Eye injuries: History of Eye Diseases: Page 2 of 6

3 Are you interested in LASIK surgery at this time? Yes If yes, would you like to speak to the Dr about your surgery options? Yes OCULAR SURFACE DISEASE SURVEY Never Slight Moderate Severe Do your eyes ever feel or do you experience: Gritty or sandy sensation? Pain or soreness? Fluctuating vision? Occasional tearing? Blurred vision while reading or computer use? Discomfort in windy conditions? Discomfort in heating/air conditioned areas? ALLERGY SURVEY Do you EVER suffer from red eyes, itchy eyes, watery eyes, or swollen eye lids? Yes If yes, please list: Do you EVER use over-the-counter or prescribed eye drops (i.e. VISINE A, VISINE AC, OPCON A, etc.) to treat red eyes, itchy eyes, watery eyes, or swollen eye lids? Yes If yes, please list: Do you take any prescribed or over the counter medications like CLARITIN, ALLEGRA, or ZYRTEC for your allergies? Yes If yes, please list: MEDICAL HISTORY Primary Care Physician: Last Physical: Do you have any allergies to medications? Yes If yes, please explain: Other Allergies (foods, pollens, etc.): Do you currently take any of the following medications? (Please check all that apply) Birth control pills Antihistamines Active bladder therapy Antidepressants Diuretics (Lasix) Accutane (even previously) Beta blockers Plaquenil Hormone replacement therapy List any medications you take below (You may also provide your list of medications and we will make a copy to keep on file): Rx or OTC/Supplements Condition Page 3 of 6

4 MEDICAL Self Family Who? Androgen Deficiency Arthritis Acne Rosacea Diabetes Cancer Facial Herpes Zoster (Shingles) Heart Disease Hepatitis C High Blood Pressure Kidney Disease Lupus Migraines Sarcoidosis Sleep Disorders Stroke Thyroid Disease Other REVIEW OF SYMPTOMS: Please list any problems you are currently having anywhere, from head to toe. General (e.g., fever, fatigue, loss of appetite, unexplained weight loss/gain): Ear, Nose, Throat (e.g., sinus/nasal congestion, nose bleeds, dry mouth/throat, sleep apnea, hearing problems): Cardiovascular (e.g., chest pain, racing heartbeat, swollen feet/ankles, TIAs): Respiratory (e.g., chronic cough, shortness of breath, wheezing): Genital, Kidney, Bladder (e.g., bladder/urinary problems, pain, discharge, menstrual changes, impotence): Gastrointestinal (e.g., constipation. diarrhea, gastric reflux (GERD), jaundice, nausea, vomiting): Endocrine (e.g., heat or cold intolerance, thinning hair, excess thirst, excess urination): Muscles, Bones, Joints (e.g., pain, stiffness, swelling, weakness, limited movements): Page 4 of 6

5 Skin (e.g., dry, itchy, flaky, rash, growths, bumps, redness, discoloration): Neurological (e.g., headaches, numbness/tingling, tremors, balance, dementia, speech problems): Psychiatric (e.g., depression, anxiety, sleeping problems, paranoia, obsessive/compulsive): Blood/Lymph (e.g., anemia, bleeding gums, delayed clotting, unexplained bruising): Allergy/Immune (e.g., swollen lymph nodes, itching, sneezing, runny nose/eyes): SOCIAL HISTORY Do you drive? Yes If yes, do you have visual difficulty when driving? Yes If yes, please describe: Do you currently use smoke or smokeless tobacco? Yes If not now, have you ever smoked? Yes Drink alcohol? Yes Do you go to school? Yes If yes, where and grade level/field of study? Do you play any sports? Yes If yes, what type and amount: Other forms of exercise? What are your hobbies? How many hours per day do you: Work on a computer: Read: Watch TV: Play Video Games: How did you hear about us? (please select all that apply): Walked/drove by building Previous patient of: Dr. Reynolds Dr. Frank Professional referral (please specify): Family/Friend referral (please specify): Page 5 of 6

6 Phone book Facebook Twitter Website Insurance company Promotion/advertisement (please specify): Print Name: Date: Signature: Page 6 of 6

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