First Name
Middle Initial
Last Name
Spouse or Parent/Guardian
Street
City
State
Zip Code
Home Phone
Work Phone
Cell Phone
Email
Employer (or School)
Occupation (or Grade)
Emergency Contact Name
Emergency Contact Phone
How would you prefer we contact you?
What is the major purpose of this visit?
Do you currently wear
Any problems with your current contact lenses or glasses?
VERY IMPORTANT! NEW PATIENTS ONLY: Who may we thank for referring you to our office? Name of a friend, relative, or Dr.
If not referred, how did you choose our office?
Please present all medical insurance cards. Please note insurance does NOT cover the Contact Lens Evaluation
Primary Medical Insurance
Subscriber Name
Subscriber ID#
Birth Date
Secondary Medical Insurance
Who is responsible for your account?
Do you . . . (check box if your answer is yes)
Date of Last Eye Exam
By Whom?
Do you currently see another eye specialist?
Have you had an eye surgery or injury?
Do you currently wear contact lenses?
Are you satisfied with the vision and comfort of your contact lenses?
Would you prefer clear or colored contact lenses?
Have you ever experienced, been diagnosed, or treated for any of the following?
The information in this confidential case history form is critical to the evaluation of your vision and health.
Do you use cigarettes/tobacco products?
Do you use alcohol products?
Do you use illegal drugs?
Have you been exposed to or infected with:
Name of Family Physician
Date of Last Medical Exam
Name of Pharmacy
CURRENT MEDICATIONS (Rx or Over the Counter)
List names of all medications including vitamins, herbs, and birth control pills. Please provide the list if available.)
CURRENT EYE DROPS (Rx or Over the Counter)
Do you have allergies to medications?
Are you pregnant or nursing?
Have you had any major surgeries?
Have you ever been diagnosed or treated for the following health problems?
CONSTITUTIONAL
Unusual weight losses or gains
Fevers
INTEGUMENTARY (skin)
NEUROLOGICAL
Migraines
Seizures
ENDOCRINE (thyroid/other gland)
CANCER
EARS / NOSE / MOUTH / THROAT
Allergies
Sinus
RESPIRATORY
COPD/Emphysema
Asthma
VASCULAR / CARDIOVASCULAR
Diabetes
Heart Disease
High Blood Pressure
High Cholesterol
GASTROINTESTINAL (stomach/intestines)
GENITOURINARY (kidney/bladder/prostate)
BONES / JOINTS / MUSCLES
Arthritis/Chronic Pain
LYMPHATIC / HEMATOLOGIC (lymph/blood)
ALLERGIC / IMMUNOLOGIC
PSYCHIATRIC / MENTAL
Doctors Signature:
Date:
All EyeCare Services
KeepIn Touch
At The EyeCare Center, we provide the highest quality eye care to all our patients. Schedule your appointment today.
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