last name

first name

M.i.

Nickname

social security #

date of birth

sexMaleFemale

Marital Status Single Married Divorced Widowed Legally Separated

race Asian Decline to Specify White American Indian or Alaska Native Black or African American Native Hawaiian or Other Pacific Islander Other Race

Ethnicity Decline to Specify Hispanic/Latino Not Hispanic/Not Latino Unknown

Mailing Address

city

state

zip code

email

physician you are seeing today: Allison Aman Bochow Cooper Kiblinger Lambson Lash Pennell Prater Whorff Wick

referring physician

city

primary care physician

city

last name

first name

m.i.

relationship to patient

Social Security #

Date of Birth

mailing address

city

state

zip code

home phone #

cell phone #

work phone #

ext.

Primary insurance company

policy #

address

group #

policy holder name

RELATIONSHIP TO PATIENT

effective date

date of birth

sex

social security #

employer

Email

employment Active Duty Full-Time Not Employed Part-Time Retired Self

Where do you work?

what is your occupation?

Preferred language English Spanish Other

StudentFull-TimePart-Time

emergency contact NOT living with you (relative, neighbor, or friend)

relationship

Emergency contact: home phone #

cell phone #

other phone #

Spouse Full Name

Phone #

Caretaker Full Name

Phone

How did you hear about eyecare associates? Family/Friend TV Radio Newspaper Yellow Pages Doctor Other

patient home phone #

patient cell phone #

patient work #

Preferred Contact By Home Phone Work Phone Cell Phone

Is it okay to leave a detailed message? Yes No

patient d.l. #

patient cell phone #

Local pharmacy

address

mail-in pharmacy

ADDRESS

date

referring physician

city

name

primary care physician

city

medical history (do you have any of the following)AsthmaArthritisCancerBreast CancerColon CancerLeukemiaLung CancerLymphomaProstate CancerDiabetesEmphysema (COPD)Heart DiseaseAtrial Fibrilation (irregular heartbeat)Coronary Artery DiseaseHepatitsHigh Cholesterol (Hypercholesterolemia)High Blood Pressure (Hypertension)HIVStrokeThyroid DiseaseHyperthyroidismHypothyroidism

Other

past surgical history

Eye conditions

eye surgeries

family history ofCataractsCrossed Eyes (Strabismus)DiabetesEye DisordersGlaucomaHeart DiseaseHigh Blood Pressure (Hypertension)Lazy Eyes (Amblyopia)Retinal Detachments

Other

drug use

alcohol use None Less than 1 drink per day 1-2 drinks per day 3 or more drinks per day

Smoking status Current every day smoker Current some days smoker Former smoker Never smoked

1) General healthNormalFever

2) EyesNormalBlurred Vision

3) Ears, nose, mouth, throatNormalHearing Loss

4) CardiovascularNormalChest Pain

5) respiratoryNormalShort of Breath

6) gastrointestinalNormalStomach Pain

7) hematologic/lymphaticNormalFree Bleeder

8) musculoskeletalNormalWeakness

9) integumentary (skin/breast)NormalTumors

10) neurologicNormalNumbness

11) genitourinaryCurrently Pregnant