PATIENT HISTORY

Name _____________________________________________        Date of Birth ____________________

Address ______________________________________________________________________________

Social Security # _______-______-________     E-Mail _________________________________________

Home Phone ___________________    Cell Phone ____________________   Work Phone ____________

Marital Status:    M   S   W   D     Race______________  Preferred Language ________________________

Last Eye Exam __________________________    Doctor _______________________________________

Last Medical Exam _______________________  Doctor _______________________________________

Occupation: ________________________  Employer _________________________________________

Referred BY ________________________________________

REASON FOR VISIT

___   Vision       ____   Medical      ____ Both      Explanation _____________________________________

___  Injury         When/ Where/ How? ______________________________________________________

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PATIENT HISTORY

Eye Conditions ________________________________________________________________________

Eye Injuries ________________________   Ocular Medications _________________________________

Surgeries (Systemic/Ocular) ______________________________________________________________

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Medical Conditions _____________________________________________________________________

Medications (Medical/Seasonal) __________________________________________________________

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Allergies (Medication/Seasonal) ___________________________________________________________

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FAMILY HISTORY

Family Eye Conditions ___________________________________________________________________

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Family Medical History __________________________________________________________________

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SOCIAL HISTORY

Tobacco Use     YES / NO          If Yes:     ___ Smoke     ___ Smokeless    ___ Former       Amount_________

Number of years of Tobacco use ______       Alcohol Use     YES  /  NO         Amount/Frequency _________

Narcotics Use    YES  /  NO                STD’s    YES  /  NO             Blood Transfusions   YES  /  NO

CONTACT LENS WEAR

Contact Lens Wearer     YES  /  NO        Type ___________________   Solutions _____________________

Replacement Plan   ____ Daily    ___ 2 Week    ___ Monthly   ___ Yearly        Hours worn per day  ______

Do you sleep in your contacts?   YES  /  NO            How often do you replace your contacts?  ___________

How many days of continuous wear ? ___________             Mono Vision or Bifocal Contacts?     YES  /  NO

Do  you have backup Glasses?    YES  /  NO

GLASSES

Did Family EyeCare Center Make your current Glasses?   YES / NO         Date of current Glasses?  YES / NO

If Family EyeCare Center DID NOT  make them where were they made? __________________________

Do you wear more than one (1) pair of Glasses?   YES / NO                   Computer Glasses?   YES / NO

Do you wear Reading Glasses?  YES / NO          Do you wear Glasses over Contact Lenses?  YES / NO

Do you wear Sports Goggles?   Yes / NO           If yes, what Sport? ________________________________

Do you wear Sunglasses?  YES / NO                   Are they Prescription Sunglasses?  YES / NO

What are your Hobbies? _________________________________________________________________

 

Additional Space if needed: ______________________________________________________________

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Patient/Guardian Signature: _______________________________________              Date:  ___________