Testimonials . . . . . . . . . Click

Patient Form

Date:

Feb 22, 2012

Name:

DOB:

Age:

Referring Doctor or Person

Eye History

Do You Wear Glasses

(check if yes )

Contact Lenses

(check if yes )

Date of Last Eye Exam

Eye Problems

Have you ever had BOTOX or Dermal Filler (i.e. Juvederm, Restylane) injections?

Yes (check if yes )

HAVE YOU EVER HAD EYE SURGERY (including laser)?

Yes (check if yes )

MEDICAL HISTORY:

Medical Doctor

Location

Phone #

Please mark any condition you or a blood relative have/indicate relationship:

YOU	RELATIVE
		High Blood Pressure
		Diabetes
		Stroke
		Arthritis
		Ulcers
		Heart Problems (Arrhythmia, Angina, Congestive,Heart Failure)
		Lung Problems (Sarcoidosis, Emphysema, COPD, Asthma)
		Thyroid Problems
		Others

List all medicines: include dosage (i.e. Mg) & how many times taken daily.

List any non-ocular surgery and date

Social History

Smoke

Yes (check if yes )

Alcohol

Yes (check if yes )

REVIEW OF SYSTEMS: (Circle or list problems you have in any area)
CONSTITUTIONAL & INTEGUMENTARY: Fever, Weight Loss, Rash, Skin Disease
HEAD/NECK: Sinus Problems, Post–Nasel Drip, Runny Nose, Dry Mouth, Hearing Loss
RESPIRATORY: Cough, Bronchitis, Shortness of Breath, Asthma, Emphysema, COPD
CARDIOVASCULAR: Chest Pain, Congestive heart Failure, Irregular Rhythm
GASTROINTESTINAL: Vomiting, Ulcers, Diarrhea, Bloody Stools
GENITOURINARY: Genital Ulcers, Discharge, Kidney Stones, Blood in Urine

We participate with most insurance providers and accept Medicare assignment

We accept Visa, MasterCard & Care Credit