Existing Patient Form Step 1 of 2 50% Name* First Last Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email* Phone*Communication PreferenceE-mailPostalTelephoneInsurance CompanyID NumberPolicy Holder's Last four digits of SS#Patient's Relationship to Policy HolderSelfSpouseChildOtherIf other, please state relationshipPolicy Holder's NamePolicy Holder's Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Eye & Health HistorySince your last eye examination in our office have you had any EYE injuries, infections, or surgeries?*YesNoPlease explainDo you have a history of any of the conditions listed below? Allergies (seasonal) Amblyopia (Lazy Eye) Blood Diseases Breathing Problems Cataracts Crossed Eyes Diabetes Digestive Conditions Ear/Nose/Throat Glaucoma Heart Disease High Blood Pressure Immune Conditions Macular Degeneration Muscle/Joint Conditions Neurological Conditions Retina Detach/Tear Skin Problems Thyroid Problems Other Please listDoes your immediate family have a history of any of the conditions listed below? Allergies (seasonal) Amblyopia (Lazy Eye) Blood Diseases Breathing Problems Cataracts Crossed Eyes Diabetes Digestive Conditions Ear/Nose/Throat Glaucoma Heart Disease High Blood Pressure Immune Conditions Macular Degeneration Muscle/Joint Conditions Neurological Conditions Retina Detach/Tear Skin Problems Thyroid Problems Other Please listPlease check all conditions that apply while wearing glasses or contacts. No complaints or concerns Poor near vision Poor distance vision Poor distance and near vision Flashes of Light Eyes burn or itch Double Vision Problems with computer vision Dry eyes Redness Eye turn Bothered by night driving Eye Strain Floaters or spots Eyes water Sensitivity to light Bothered by glare Do you currently wear contacts?*YesNoDo you want to be fit with contacts?*YesNoPlease list current medications and/or vitamins:Medications you are allergic to:Other known allergies:Are you experiencing headaches?YesNoSmoking StatusNeverQuitCurrentAlcohol ConsumptionNever/Occasionally1-2 Per Day>2 Per DayIf you are a woman, are you currently pregnant or nursing?YesNo
