Last Name:
  First Name:
  Mailing Address:
  Home Phone:
  Work Phone:
  Mobile Phone:
  Email Address:
  Fax Number: Fax Number:
  Date of Birth
  Name of Parent or Spouse:
  Children: Yes No
Ages:
  Have We Treated Other Family Members? Yes No
Whom:
  Occupation:
  Employer:
  If Student, What Grade?
  Hobbies:
  Do you work in front of computers?
     
  Optical Information:  
  Which Location are you Going to Visit? Carrollton Richardson
Dallas Frisco
  When was your last exam?
  Where was it?
  Who was your last eye doctor?
  What was the doctor's phone number?
  Have dilation drops ever caused you unusual problems? Yes No
If so what?
  Have you ever worn glasses? Yes No
If so, how old were you when first prescribed?
  Do you wear contacts? Yes No
  Are you satisfied with them? Please explain:
  Professional fees must be paid for at the time services are rendad. This visit will be paid by:
     
  Purpose of Exam:  
  What need or concern brought you here today?
  How can we help you?
  How did you hear about us?
     
  Health History:  
  How would you describe your general health?
  Do you put your health at risk? Yes No
  If so, How?
  What are your major health problems?
  Name of family physician?
  His/Her Phone Number
     
  Individual AND Family History
  Check YES if pertaining to you or blood relatives
     
Yes
No
  Glaucoma
  Optic Nerve, neurological diseases, multiple sclerosis blindness
  Cataract
  Color Deficiency
  Retinal Problems, Detachments, Macular Degeneration
  "Lazy Eye"/ Eye "Turns"
  Any Other Eye Problems (i.e. keratoconus, retintis pigmentosa)
  Kidney Problems
  Diabetes
  Thyroid
  Chronic Inflammatory Diseases (i.e. Lupus, Gout, Rheumatoid, Colitis)
  Allergies, Sinus Problems
  Hives, Eczema, Seborhea
  Asthma, Chronic Bronchitis
   
  Individual History
  Check YES if pertaining to you...
   
Yes
No
  Eye Surgery, Disease, Injury, R.K.
  Head Injuries
  Eye Pain, Soreness, Tiredness
  Excessive or Frequent Headaches
  Serious or Frequent Eye Infections, Iritis, "Scratched" Eyes
  Burning, Scratchy, Dry Eyes, Frequent Use of Eye Drops
  Itchy, mucousy eyes, G.P.C.
  Decreased Night Vision
  Decreased Near Vision
  Double Vision
  Variable Vision
  Foggy Vision
  Sparks, Light Flashes
  Red Eyes
  Styes, Flaky Lids, Pink Lids, Thin Lash Line
  Sleeping with Eyes Partially Open
  Drug Allergies?
  If so what:
  Medications Currently or Frequently Used?
  Physical Defects, Past Major Illnesses, Surgeries?
  Medical Problems Currently Treated?