Last Name_____________________     First Name ________________  M.I. ___        Home# ( _____ ) _______________   
Date of Birth ________ Age ___Male/Female ___ Social Security # _____ - __ - _____   Cell # (_____)______________
Primary Language :English____  Other____________  Race______________ Ethnicity____________ Decline Info___

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

Reason for today's visit:  __________________________________________________________________________

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

Your Secondary Insurance Co. _________________________ ID # _____________________  Group # _________
Subscriber's Last Name _________________________ First Name __________________    Date of Birth _____________
Subscriber's Social Security # ______ - ____ - _________   Relationship to insured ______________________________
Your Employer's Name and Address ______________________________________________________________________


Secondary Insurance______________________________ ID #______________________  Group #_________________
Subscriber's Last Name_________________________ First Name_________________ Date of Birth_______________
Subscriber's Social Security #______ - ____ - ________       Relationship to insured ____________________________

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 ____________________________________
___________________________________________________________________________

Preferred Pharmacy Name and address _______________________________________________________________
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?  Never_____  Yes (every day) _____    Yes (some days) _____     Former smoker_______

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 ___________________________________________________________________