Last Name_____________________   First Name ________________  M.I. ____    
Home Tel # ( ____ ) _________________    Cell Phone #  ( _____ ) __________________

Date of Birth _____________   Age ____   Male/Female ____   Social Security Number ______ - ____ - ________

Home Address _______________________________ Apt. # ___   City __________________  State ____ Zip______
Your occupation ______________________________ Marital Status:  Single ____  Married ____  Widowed _____
Your email ____________________ @ ______________________ Primary Care Physician _____________________ 

Reason for today's visit:   Routine eye exam ____ Other ____________________________________________

Primary Insurance Co. __________________ ID # _______________________  Group # _______________
Subscriber's Last Name _____________________ First Name ________________ Date of Birth _______________
Relationship to insured _________________ Subscribers Social Security Number _______  ____  ________

Your Secondary Insurance Co. _________________________ ID # _____________________  Group # _________
Subscriber's Last Name _____________________ First Name _______________  Date of Birth _______________

Your Employer's Name and Address _____________________________________________________________

Eye History (please check ALL applicable):
 Glasses ____Contact Lenses ____ Glaucoma ____ Cataract ____  Dry Eyes ____ Macular Degeneration ____
  History of Lazy or Crossed Eye _____    Previous EYE Surgery (describe) _____________________________
  _____________________________________________________________________
 Eye Drops or other EYE Medications taken ________________________________________________________

Medical History (please check ALL applicable):
  Diabetes _____  High Blood Pressure _____  Arthritis _____ Sinus Problems _____  HIV Positive _____
   Thyroid Disease _____   Hepatitis ____  Other Diseases _____________________________________________

Please list all NON EYE medications you take including non-prescription _________________________________________
________________________________________________________________________________________________

Drug allergies or intolerance  None _____   Penicillin _____  Sulfa ______  Other (list) ______________________

Previous NON-EYE surgery (list) ________________________________________________________________

Do you have any blood relatives with glaucoma?  Yes __ No ___     Macular degeneration ?  Yes __ No ___
Do you smoke?  No __ Yes (how much?) _______________ Do you drink?   No __ Yes (how much) ___________

Other Medical Complaints (please check all applicable):

Headache ___ Skin Rash ___   Chest Pain ___  Palpitations____ Fever ____  Kidney/Bladder problems ____ 
Joint Pain/Swelling ____  Prostate Problems  ____  Breast Lumps ___ Hay Fever / Allergies____
Numbness/Tingling ____  Bleeding Problems ____ Sinus Problems ____       Breathing Problems ___
Seizures ____  Abnormal Blood ____  Hearing Problems ____    Digestive Problems ____ Appetite Loss ____
Emotional Problems ____  Other ___________________________________________________________________

Additional Information: