PatientInformation
NAME_____________________________________________ BIRTH DATE_____/_____/______ SEX_________
SOCIAL SECURITY NUMBER______________________________ EMAIL____________________________________________
ADDRESS_________________________________________________________________________________________________
CITY_______________________________________ STATE______________________________ ZIP______________________
HOME PHONE NUMBER______________________ OCCUPATION_________________________________
EMPLOYER__________________________________WORK PHONE NUMBER______________________________________
CITY_______________________________________ STATE______________________________ ZIP______________________
SPOUSE INFORMATION OR PARENT IF PATIENT IS UNDER 18 YEARS OF AGE
NAME_____________________________________________ SPOUSE PARENT
SOCIAL SECURITY NUMBER______________________________
ADDRESS_________________________________________________________________________________________________
CITY_______________________________________ STATE______________________________ ZIP______________________
OCCUPATION_________________________________ WORK PHONE NUMBER_____________________________________
VISION INSURANCE: BCBS VSP EYEMED MEDICARE MEDICAID CIMMARRON OTHER___________________
HEALTH INSURANCE: BCBS GREATWEST MEDICARE CIMARRON OTHER______________________________
REFERRED BY____________________________________________________
PAYMENT IS REQUIRED AT THE TIME SERVICES ARE RENDERED. THERE WILL BE A $30 SERVICE CHARGE ON ALL RETURNED CHECKS.
_________________________________________________
PERSON RESPONSIBLE FOR PAYMENT
1. Age of present glasses_______________________Date of last eye exam________________from Dr._____________________________
2. What sports or hobbies do you enjoy?________________________________________________________________________________
3. Do you or any family members have any of the following: diabetes - yes / no who?________________________________
high blood pressure yes / no who?___________________ cataracts yes / no who?________________________________
glaucoma yes / no who?___________________retinal detachment yes / no who?___________________________
retinal degeneration yes / no who?___________________macular degeneration yes / no who?__________________________
lung disease yes / no who?___________________ thyroid problems yes / no who?___________________________
heart problems yes / no who?___________________collagen vascular disease yes / no who?________________________
arthritis yes / no who?___________________cancer yes / no who?___________________________
other health concerns ____________________________________________
4. Are you currently taking any medication? Yes / No please list_________________________________________________________ _____________________________________________________________________________________________________________
5. Are you allergic to any medication? Yes / No please list________________________________________________________________
6. Do you smoke? Yes / No
7. Do you have any other allergies? (food, seasonal, etc) Yes / No please list ________________________________________________
8. Have you ever had an eye infection, disease, injury, or surgery? Yes / No please list _________________________________________
9. Do your eyes burn, itch or tear unusually? Yes / No when____________________________________________________________
10. Have you ever seen flashes of light or floaters in you vision? Yes / No when_______________________________________________
11. Do you ever see double? Yes / No when____________________________________________________________
12. Do you have frequent headaches? Yes / No when____________________________________________________________
13. Are you pregnant or nursing? Yes / No when____________________________________________________________
14. Do you have trouble with night vision? Yes / No conditions?_______________________________________________________
15. Have you ever worn contacts? Yes / No If no, interested? Yes / No
16. Do you currently wear contacts? Yes / No type of contacts______________________solutions__________________
17. Do you work on a computer? Yes / No hours per day___________________________________________________
18. Do you plan on purchasing glasses or contact lenses today? Yes / No
19. Are you interested in LASIK or any other form of laser surgery? Yes / No
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