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1.704.821.3937
6044 W Hwy 74, Indian Trail, NC 28079
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Patient Information
Patient Information
Welcome to our office! We want to provide you with the very best in eye care. To serve you better, we need certain biographical information. Please complete the following data for our records.
PATIENT INFORMATION
Name
*
First
Middle
Last
Social Security
*
Gender
*
Male
Female
Marital Status
Single
Married
Other
Address
*
Mailing Address
City
State / Province / Region
ZIP / Postal Code
Phone
*
Alternative Number
Email
*
Whom may we thank for referring you to us?
Eye Health History
Symptoms
*
How can we help you today? Please circle to indicate if you currently have any of the following symptoms, please indicate which eye:
Annual Examination
Eye Infection
Eye Injury
Twitching Eyelid
Light Sensitive
Discharge from Eyes
Burning Eyes
Watering Eyes
Red Eyes
Dry Eyes
Blurred Vision- Near
Sandy/Gritty Eyes
Itchy eyes
Temporary Loss of Vision
Blurred Vision- Far
Blurred Vision- Far
Seeing Halos
Fluctuating Vision
Seeing Flashes
Floaters, Spots
Double Vision
Crossed Eyes
Color Vision, Poor
Eye Strain
Eye Turn
Glaucoma
Cataracts
Other Symptoms
CURRENT VISION
Date of Last Eye Exam
*
Month
Day
Year
Doctor
Are you interested in wearing contact lenses?
*
Yes
No
How many hours per day do you work on a computer?
*
Have you had LASIK?
*
Yes
No
Are you interested in LASIK?
*
Yes
No
Do you currently wear glasses?
*
Yes
No
If so, how old are your glasses?
Are you interested in getting new glasses today?
*
Yes
No
CONTACT LENSES: Do you currently wear contacts?
*
Yes
No
How often do you replace your contact lenses?
Daily
Weekly
Monthly
3 Months
6 Months
Annually
What solution do you use to care for contact lenses?
Biotrue
Opti-free
Clear Care
Boston
Other
Do you use any contact lens rewetting drops or artificial tears to improve the comfort of your lenses?
Yes
No
What rewetting drops or artificial tears do you use?
Describe any problems or frustrations with your contact lenses:
REVIEW OF SYSTEMS
Have you been diagnosed with any of the following conditions?
Ocular/Eye Problems
Please select all diagnoses that apply
Inflammatory disorder
Surgery
Glaucoma
Amblyopia (lazy eye)
Cataract
Retinal problems
Macular degeneration
Strabismus (eye turn)
Patching
Constitutional Problems
Please select all diagnoses that apply
Cancer
Fatigue
Development disability
Ears, Nose, Mouth, Throat Problems
Please select all diagnoses that apply
Laryngitis
Dry mouth
Hearing loss
Sinusitis
Neurological Problems
Please select all diagnoses that apply
Cerebral palsy
Multiple sclerosis
Tumor
Epilepsy
Psychiatric Problems
Please select all diagnoses that apply
Depression
Insomnia
Cardiovascular Problems
Please select all diagnoses that apply
Vascular disease
Stroke
Congestive heart failure
Heart disease
High blood pressure
High Cholesterol
Respiratory Problems
Please select all diagnoses that apply
Emphysema
Bronchitis
Smoker
COPD
Asthma
Gastrointestinal Problems
Please select all diagnoses that apply
Colitis
Crohn’s disease
Ulcer
Acid Reflux
Genitourinary Problems
Please select all diagnoses that apply
Prostate Disease/Cancer
STD
Kidney Disease
Musculoskelatal Problems
Please select all diagnoses that apply
Ankylosis Spondylitis
Fibromyalgia
Muscular Dystrophy
Osteoarthritis
Skin Problems
Please select all diagnoses that apply
Rosacea
Psoriasis
Eczema
Endocrine Problems
Please select all diagnoses that apply
Diabetes Insulin-Dependent
Diabetes Non-Insulin
Hormonal Dysfunction
Thyroid Dysfunction
Blood/Lymph Problems
Please select all diagnoses that apply
Large volume blood loss
Anemia
Allergy/Immunologic Problems
Please select all diagnoses that apply
Environmental allergies
Rheumatoid Arthritis
Lupus
Are you pregnant or nursing?
*
Yes
No
What is your occupation?
*
List your sports / hobbies:
*
Do you Smoke?
Yes
No
If you smoke, how much per day?
Do you consume alcohol?
*
Yes
No
Primary Care Physician
*
Please list any medications you currently taking
List any medicine allergies
*
List any other allergies
*
Other condition not listed
FAMILY HISTORY
Has anyone in your immediate family been diagnosed with the following conditions? If so, please check the appropriate box
MOTHER
*
None
Diabetes
High Blood Pressure
Glaucoma
Macular Degeneration
FATHER
*
None
Diabetes
High Blood Pressure
Glaucoma
Macular Degeneration
SIBLING
*
None
Diabetes
High Blood Pressure
Glaucoma
Macular Degeneration
GRANDMOTHER
*
None
Diabetes
High Blood Pressure
Glaucoma
Macular Degeneration
GRANDFATHER
*
None
Diabetes
High Blood Pressure
Glaucoma
Macular Degeneration
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