Prefix Mr. Mrs. Miss Ms. Dr. Prof. Rev.
Please provide a telephone number, with area code, so we can contact you:
Preferred Language* English Spanish French Japanese Decline to specify
Race* American Indian or Alaska Native Asian Black or African American Hispanic Native Hawaiian or Pacific Islander White Decline to specify
Ethnicity* Decline to specify Hispanic or Latino Native Hawaiian or other Pacific Islander Not Hispanic or Latino
Marital Status Divorced Legally Separated Married Single Widowed Other
Employment Status Employed Full-Time Employed Part-Time Not Employed On Active Military Duty Retired Self-Employed Student Full-Time Student Part-Time Other
How were you referred to our office? Friend or Family Family Doctor Ophthalmologist Insurance Company Newspaper Television Radio Other Received Mailing Internet Other Optometrist Other
Do you drink alcohol? No Yes, 1 per week Yes, 1 per day Yes, 2 or 3 per day Yes, 4 or more per day
Do you smoke? No Yes, 1/2 a pack per day Yes, 1 pack per day Yes, more than 1 pack per day
Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)
Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)
Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)
Please list all hospital surgeries you have ever had:
Please list all prescription and over-the-counter medications you take and for what conditions
Please list all drug allergies you have
Please check off any current conditions you suffer from
Primary Insurance Bring all insurance cards with you to your appointment.
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