Patient Information Form Completing and submitting the following information prior to your appointment will help us make your visit more punctual and thorough. Patient Name* Mr.Mrs.Ms.Dr.Other Salutation First Middle Last Suffix Date of Birth* Month Day Year Age*Drivers License NumberIssuing StateExpires On Month Day Year Address* Street Address Apartment/Suite City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Contact's Home Phone*Contact's Mobile Phone*Contact's Email* Patient OccupationPatient EmployerWork PhoneLast 4-digits of Social Security #Primary Insured Social Security # (Last 4-digits only)Is this your first visit to our office?* Yes No If yes, please tell us who referred you:Please tell us the reason(s) for your upcoming visit:(Check all that apply) Exam Glasses Contacts Eye Infection or Injury Laser Vision Consultation Medical Problem If other, please explain:Are you planning to get new glasses on this visit? Yes No If neccessary If you participate in any sports list them here: Insurance InformationMedical Insurance CompanyMedical Policy #Medical Group #Medicare #Vision Insurance CompanyVision Policy #Vision Group #Medical HistoryTo help our office better serve your specific needs, please check all that apply. Please leave boxes unchecked for a NO answer.Eye History Headaches Glare Light Sensitivity Tired Eyes Eye Infection Excess Tearing/Watering Redness Drooping Eyelid Sandy or Gritty Feeling Itching Crossed Eyes Blurred Vision Distance Dryness Floaters or Spots Distorted Vision (halos) Burning Loss of Side Vision Foreign Body Sensation Loss of Vision Macular Degeneration Retinal Detachment Glaucoma Color Blindness Blindness Diabetic Retinopathy Amblyopia(lazy eye) Eye Pain or Soreness Fluctuating Vision Double Vision Blurred Vision Near Mucous Discharge Cataract(s) Other General Health Condition Kidney Fever Muscles, Bones, Joints Ears, Nose, Throat Allergic Respiratory (Asthma) Neurological Skin Psychiatric Joint Pain Endocrine Cardiovascular Disease Bleeding Problems Anemia Heart Disease Diabetes Genitals/Kidney/Bladder Cancer Pregnant or Nursing Sinus Congestion Runny Nose Smoke Cigarettes Post-Nasal Drip Chronic Cough Consume Alcohol Lupus Stroke High Blood Pressure Other System Thyroid Disease Dry Throat/ Mouth Chronic Bronchitis Emphysema Rheumatoid Arthritis AIDS/HIV Blood/Lymph Gastrointestinal Weight Loss Please provide your family doctor's name, address and contact information:Family History Stroke Arthritis Macular Degeneration Amblyopia (Lazy Eye) Cancer Retinal Detachment Glaucoma Lupus Crossed Eyes High Blood Pressure Diabetes Cataract(s) Color Blindness Other Blindness Thyroid Disease Kidney Disease Heart Disease Currently taking medication(s) - prescription and/or over the counterMedicationSelect from listAccuprilAcetaminophenAcetazolamideAdalat CCAdderallAlbuterolAllegraAllopurinolAlphaganAlprazolamApraclonidineAmbienAmitriptylineAmoxicillinAtenololAugmentinB-12Betoptic (sel)Betoptic-S (sel)Betimol (non-sel)BiaxinBuSparCalciumCardizem CDCarduraCelebrexCephalexinCreonCiloxinCiprofloxacinClaritinClonidineCosoptCourmadinCozaarDepakoteDiazepamDiflucanDilantinEstraceFlonaseFlour-opFloventFML (flourometholone)FosamaxFurosemideGemfibrozilGlucophageGlucotrol XLGlyburideHydrochlorothiazideHydrocodoneHytrinIbuprofenInflamase Forte 1%InsulinIsosorbideK-DurLanoxinLevoxylLipitorLorazepamLotemax .5%LotensinMethazolamideMetipranolol (nol-sel)MevacorNaproxenNorvascNeurotoninOcupressOrtho Tri-CyclenOrtho-NovumOrth-CyclenOxybutinPaxilPenincillinPepcidPhenobarbatolPolytrimPotassium ChloridePravacholPred Forte 1%PrednisonePremarinPremproPrevacidPrilosecPrinivilProcardia XLPropranololPropulsidProventilProzacSynthroidTamoxifenTimolol (non-sel)Timoptic XE (non-sel)TobradexToprol-XLTrazodoneTriamtereneTrimethoprimTrimoxTriphasilTrusoptUltramVasotecVerapamilVexol 1%ViagraVioxxWellbutrin SRXalatan (latanaprost)ZestrilZithromaxZocorZoloftZyrtecReasonSelect from listn/aAllergiesArthritisBlood/lymphCancerDiabetesCardiovascularCholesterolContraceptionDepressionEarsNoseThroatEndocrineGastrointestinalGlaucomaHeadachesHypertensionIncontinenceKidneyMusclesBonesJointsNeurologicalPsychiatricRespiratorySeizuresSinusSkinSulfa DrugsThyroidWater RetentionWeight LossMedicationSelect from listAccuprilAcetaminophenAcetazolamideAdalat CCAdderallAlbuterolAllegraAllopurinolAlphaganAlprazolamApraclonidineAmbienAmitriptylineAmoxicillinAtenololAugmentinB-12Betoptic (sel)Betoptic-S (sel)Betimol (non-sel)BiaxinBuSparCalciumCardizem CDCarduraCelebrexCephalexinCreonCiloxinCiprofloxacinClaritinClonidineCosoptCourmadinCozaarDepakoteDiazepamDiflucanDilantinEstraceFlonaseFlour-opFloventFML (flourometholone)FosamaxFurosemideGemfibrozilGlucophageGlucotrol XLGlyburideHydrochlorothiazideHydrocodoneHytrinIbuprofenInflamase Forte 1%InsulinIsosorbideK-DurLanoxinLevoxylLipitorLorazepamLotemax .5%LotensinMethazolamideMetipranolol (nol-sel)MevacorNaproxenNorvascNeurotoninOcupressOrtho Tri-CyclenOrtho-NovumOrth-CyclenOxybutinPaxilPenincillinPepcidPhenobarbatolPolytrimPotassium ChloridePravacholPred Forte 1%PrednisonePremarinPremproPrevacidPrilosecPrinivilProcardia XLPropranololPropulsidProventilProzacSynthroidTamoxifenTimolol (non-sel)Timoptic XE (non-sel)TobradexToprol-XLTrazodoneTriamtereneTrimethoprimTrimoxTriphasilTrusoptUltramVasotecVerapamilVexol 1%ViagraVioxxWellbutrin SRXalatan (latanaprost)ZestrilZithromaxZocorZoloftZyrtecReasonSelect from listn/aAllergiesArthritisBlood/lymphCancerDiabetesCardiovascularCholesterolContraceptionDepressionEarsNoseThroatEndocrineGastrointestinalGlaucomaHeadachesHypertensionIncontinenceKidneyMusclesBonesJointsNeurologicalPsychiatricRespiratorySeizuresSinusSkinSulfa DrugsThyroidWater RetentionWeight LossMedicationSelect from listAccuprilAcetaminophenAcetazolamideAdalat CCAdderallAlbuterolAllegraAllopurinolAlphaganAlprazolamApraclonidineAmbienAmitriptylineAmoxicillinAtenololAugmentinB-12Betoptic (sel)Betoptic-S (sel)Betimol (non-sel)BiaxinBuSparCalciumCardizem CDCarduraCelebrexCephalexinCreonCiloxinCiprofloxacinClaritinClonidineCosoptCourmadinCozaarDepakoteDiazepamDiflucanDilantinEstraceFlonaseFlour-opFloventFML (flourometholone)FosamaxFurosemideGemfibrozilGlucophageGlucotrol XLGlyburideHydrochlorothiazideHydrocodoneHytrinIbuprofenInflamase Forte 1%InsulinIsosorbideK-DurLanoxinLevoxylLipitorLorazepamLotemax .5%LotensinMethazolamideMetipranolol (nol-sel)MevacorNaproxenNorvascNeurotoninOcupressOrtho Tri-CyclenOrtho-NovumOrth-CyclenOxybutinPaxilPenincillinPepcidPhenobarbatolPolytrimPotassium ChloridePravacholPred Forte 1%PrednisonePremarinPremproPrevacidPrilosecPrinivilProcardia XLPropranololPropulsidProventilProzacSynthroidTamoxifenTimolol (non-sel)Timoptic XE (non-sel)TobradexToprol-XLTrazodoneTriamtereneTrimethoprimTrimoxTriphasilTrusoptUltramVasotecVerapamilVexol 1%ViagraVioxxWellbutrin SRXalatan (latanaprost)ZestrilZithromaxZocorZoloftZyrtecReasonSelect from listn/aAllergiesArthritisBlood/lymphCancerDiabetesCardiovascularCholesterolContraceptionDepressionEarsNoseThroatEndocrineGastrointestinalGlaucomaHeadachesHypertensionIncontinenceKidneyMusclesBonesJointsNeurologicalPsychiatricRespiratorySeizuresSinusSkinSulfa DrugsThyroidWater RetentionWeight LossMedicationSelect from listAccuprilAcetaminophenAcetazolamideAdalat CCAdderallAlbuterolAllegraAllopurinolAlphaganAlprazolamApraclonidineAmbienAmitriptylineAmoxicillinAtenololAugmentinB-12Betoptic (sel)Betoptic-S (sel)Betimol (non-sel)BiaxinBuSparCalciumCardizem CDCarduraCelebrexCephalexinCreonCiloxinCiprofloxacinClaritinClonidineCosoptCourmadinCozaarDepakoteDiazepamDiflucanDilantinEstraceFlonaseFlour-opFloventFML (flourometholone)FosamaxFurosemideGemfibrozilGlucophageGlucotrol XLGlyburideHydrochlorothiazideHydrocodoneHytrinIbuprofenInflamase Forte 1%InsulinIsosorbideK-DurLanoxinLevoxylLipitorLorazepamLotemax .5%LotensinMethazolamideMetipranolol (nol-sel)MevacorNaproxenNorvascNeurotoninOcupressOrtho Tri-CyclenOrtho-NovumOrth-CyclenOxybutinPaxilPenincillinPepcidPhenobarbatolPolytrimPotassium ChloridePravacholPred Forte 1%PrednisonePremarinPremproPrevacidPrilosecPrinivilProcardia XLPropranololPropulsidProventilProzacSynthroidTamoxifenTimolol (non-sel)Timoptic XE (non-sel)TobradexToprol-XLTrazodoneTriamtereneTrimethoprimTrimoxTriphasilTrusoptUltramVasotecVerapamilVexol 1%ViagraVioxxWellbutrin SRXalatan (latanaprost)ZestrilZithromaxZocorZoloftZyrtecReasonSelect from listn/aAllergiesArthritisBlood/lymphCancerDiabetesCardiovascularCholesterolContraceptionDepressionEarsNoseThroatEndocrineGastrointestinalGlaucomaHeadachesHypertensionIncontinenceKidneyMusclesBonesJointsNeurologicalPsychiatricRespiratorySeizuresSinusSkinSulfa DrugsThyroidWater RetentionWeight LossMedicationSelect from listAccuprilAcetaminophenAcetazolamideAdalat CCAdderallAlbuterolAllegraAllopurinolAlphaganAlprazolamApraclonidineAmbienAmitriptylineAmoxicillinAtenololAugmentinB-12Betoptic (sel)Betoptic-S (sel)Betimol (non-sel)BiaxinBuSparCalciumCardizem CDCarduraCelebrexCephalexinCreonCiloxinCiprofloxacinClaritinClonidineCosoptCourmadinCozaarDepakoteDiazepamDiflucanDilantinEstraceFlonaseFlour-opFloventFML (flourometholone)FosamaxFurosemideGemfibrozilGlucophageGlucotrol XLGlyburideHydrochlorothiazideHydrocodoneHytrinIbuprofenInflamase Forte 1%InsulinIsosorbideK-DurLanoxinLevoxylLipitorLorazepamLotemax .5%LotensinMethazolamideMetipranolol (nol-sel)MevacorNaproxenNorvascNeurotoninOcupressOrtho Tri-CyclenOrtho-NovumOrth-CyclenOxybutinPaxilPenincillinPepcidPhenobarbatolPolytrimPotassium ChloridePravacholPred Forte 1%PrednisonePremarinPremproPrevacidPrilosecPrinivilProcardia XLPropranololPropulsidProventilProzacSynthroidTamoxifenTimolol (non-sel)Timoptic XE (non-sel)TobradexToprol-XLTrazodoneTriamtereneTrimethoprimTrimoxTriphasilTrusoptUltramVasotecVerapamilVexol 1%ViagraVioxxWellbutrin SRXalatan (latanaprost)ZestrilZithromaxZocorZoloftZyrtecReasonSelect from listn/aAllergiesArthritisBlood/lymphCancerDiabetesCardiovascularCholesterolContraceptionDepressionEarsNoseThroatEndocrineGastrointestinalGlaucomaHeadachesHypertensionIncontinenceKidneyMusclesBonesJointsNeurologicalPsychiatricRespiratorySeizuresSinusSkinSulfa DrugsThyroidWater RetentionWeight LossIf you take additional medications, please list them here: Do you have any drug allergies?* Yes No If yes, please list the medication(s): Δ
