Adult Patient Form Patient Form - ADULT Date MM slash DD slash YYYY Name First Middle Last DOB: MM slash DD slash YYYY Female Male Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Home PhoneCell #Preferred Contact Name & Number:Email Marital Status: Single Married Other Name of Spouse/Partner: First Last Were you referred to our office? Yes No Whom may we thank for referring you?Please fill out name, location, & contact information of the referral source.Name of professional who referred you:Address of professional who referred you: Street Address City ZIP Code PhoneFaxEmail Do we have permission to communicate findings with referral source? Yes No If not referred, how did you hear about us?Is your condition the result of an accident or injury?Explain type of injury/accident, and how received:Date of injury: MM slash DD slash YYYY is it work related?Name of Auto or Workman's Comp Carrier:Address Street Address City State / Province / Region ZIP / Postal Code Adjuster Name: First Last PhoneClaim#ADULT EYE HEALTH HISTORYWhen was your last eye exam? MM slash DD slash YYYY Where:Who is your Primary Care Physician?Do you have any MEDICATION ALLERGIES? Yes No If so, to what?Please list all MEDICATIONS YOU CURRENTLY USE (including over the counter, eye drops and supplements): Add RemoveList all EYE SURGERIES or INJURIES: Add RemoveHave you been diagnosed with any of the following EYE CONDITIONS? (Check all that apply) Cataract Thyroid Eye Disease Corneal Dystrophy Blindness Hypertensive Retinal Disease Macular Degeneration Eye/Eyelid Cancer Implant Lens Retinal Detachment Glaucoma Dry Eye Syndrome Diabetic Retinal Disease Strabismus/Wandering Eye Amblyopia/Lazy Eye (if yes complete Strabismus/Amblyopia tab) Other Eye Conditions:Check any of the following symptoms you experience: Eye Pain Flashes of Light Change in Distance Vision Dryness or Burning In Eyes Light Sensitivity Change in Near Vision New Spots or Floaters Fluctuating Vision Eye Itching Excess Tearing Sandy or Gritty Feeling Double Vision Mucus Discharge or Crusted Lids Loss of Side Vision Dizziness Car Sickness Eyestrain Other vision-related symptoms:VISION HISTORY:What is your primary vision correction? Glasses Contacts Neither Have you ever worn contact lenses? Yes No specify Soft Rigid gas-permeable (RGP) Hybrid Scleral lenses Are you interested in contact lenses? Yes No please bring your current prescription information with you!If you wear contact lenses, are they comfortable and working well for you? Yes No Do you have additional glasses (backup, reading, computer, sun, music, sports, etc.)? Yes No What is your primary occupation?How many hours per day do you work on a computer?(Reading & Computer Checklist)Please answer the following questions about how your eyes feel when reading or doing close work. Do your eyes feel tired when reading or doing close work? Never Infrequently Sometimes Frequently Always Do you have headaches when reading or doing close work? Never Infrequently Sometimes Frequently Always Do you lose concentration when reading or doing close work? Never Infrequently Sometimes Frequently Always Do you have trouble remembering what you have read? Never Infrequently Sometimes Frequently Always Please answer the following questions about how your eyes feel when reading or doing close work.Do you have double vision when reading or doing close work? Never Infrequently Sometimes Frequently Always Do you see the words move, jump, and swim or appear to float on the page when reading or doing close work? Never Infrequently Sometimes Frequently Always Do you feel like you read slowly? Never Infrequently Sometimes Frequently Always Do your eyes ever hurt when reading or doing close work? Never Infrequently Sometimes Frequently Always Do you feel a "pulling" feeling around your eyes when reading or doing close work? Never Infrequently Sometimes Frequently Always Do you notice the words blurring or coming in and out of focus when reading or doing close work? Never Infrequently Sometimes Frequently Always Do you lose your place when reading or doing close work? Never Infrequently Sometimes Frequently Always Do you have to reread the same line or words when reading? Never Infrequently Sometimes Frequently Always In addition: (Check all that apply): Tendency to close or cover one eye Confuse similar-looking words Poor reading comprehension poor visual-motor (eye-hand, eye-foot) coordination Difficulty tracking moving objects, balls, etc. Misalignment of digits or columns of numbers Comprehension decreases over time Does not visualize Difficulty completing assignments in the time allotted List your hobbies or other activities: Add RemoveReview of Systems: Do you currently, or have you ever had, any problems in the following areas:1. Eyes:Itching Yes No double vision Yes No Burning Yes No Matted Eyelashes/Lashes Sticking Together Yes No Loss of Vision Yes No Redness Yes No light sensitivity Yes No Floaters Yes No Loss of Sharpness Yes No flashes of light Yes No Tearing Yes No Other2. ConstitutionalDevelopmental Disorders Yes No Cancer Yes No Fatigue Syndrome Yes No Other3. Ear, Nose, MouthSinusitis Yes No Dry Mouth Yes No Hearing Loss Yes No Laryngitis Yes No Other4. Neurological:Epilepsy Yes No Multiple Seizures Yes No Tumor Yes No Cerebral Palsy Yes No Stroke/CVA Yes No Migraine Yes No Parkinson's Yes No Other5. Psychiatric:Depression Yes No Bipolar Disorder Yes No Anxiety Yes No Attention Deficit Disorder (ADD/ADHD) Yes No Other6. Cardiovascular:Stroke Yes No Heart Disease Yes No High Blood Pressure Yes No Congestive Heart Failure Yes No Other7. Respiratory:Cigarette Smoker Yes No Bronchitis Yes No COPD Yes No Emphysema Yes No Asthma Yes No Sleep Apnea Yes No Other8. Gastrointestinal: Celiac Disease Yes No Crohn's Disease Yes No Ulcer Yes No Colitis Yes No Acid Reflux Yes No Other9. Genitourinary:Kidney Disease Yes No STD - Herpetic/Chlamydia Yes No Prostate Disease/Cancer Yes No Pregnant/Nursing Yes No Other10. Musculoskeletal: Arthritis Yes No Ankylosing Spondylitis Yes No Fibromyalgia Yes No Muscular Dystrophy Yes No Osteoarthritis Yes No Gout Yes No Other11. Integumentary:Herpes Simplex/Cold Sores Yes No Herpes Zoster/Shingles Yes No Rosacea Yes No Psoriasis Yes No Eczema Yes No Other12. Endocrine:Diabetes Type I Yes No Diabetes Type II Yes No Thyroid Dysfunction Yes No Hormonal Dysfunction Yes No Other13. Hematologic/Lymphatic:Anemia Yes No Ulcer Yes No High Cholesterol Yes No Other14. Hematologic/Lymphatic:Environmental Allergies Yes No to what?Lupus Yes No Rheumatoid Arthritis Yes No to what?Drug Allergies Yes No If you answered yes to any of the above, or have a condition not listed, please explain:List any other conditions (such as Autism, Down syndrome, ADD, ADHD, Speech Impaired, etc). Add RemoveDo you use any of the following? Alcohol Tobacco Recreational Drugs Frequency:Frequency:Frequency:FAMILY HISTORY:Is there a history of any of the following conditions in your family? Glaucoma Rheumatoid Arthritis Diabetes Retinal Disease Retinal Detachment Crossed or Wandering Eye Macular Degeneration Albinism Amblyopia/Lazy Eye Please list relation to each relative for each condition marked Add RemoveOther Family History of Eye Conditions? Δ
