MEDICAL HISTORY

Do you have any allergies to medications? Yes No If yes, explain:List any medications you take and what conditions you take them for (Including eyedrops, oral contraceptives, aspirin, over the counter medications,home remedies, vitamins)

List all major surgeries and/or hospitalizations you have had:

Check any of the following that you have had:

crossed eyes lazy eye drooping eyelid prominent eyes macular degeneration glaucoma

Describe further:

SPECTACLES HISTORY

Do you wear glasses? Yes No If yes, how old is your current prescription? Do you wear them full time part time Type of Glasses

distance reading computer/o�ce If yes, speci�c anti-glare tinits or coatings? Yes No single vision bifocals trifocals progressivesback up safety sports sun If yes, are they prescription sunglasses? Yes No special eyewear needs occupational (mechanics, plumbers, pilots) safety Glasses (gardening, woodworkings, welding) sports/hobbies (raquet sports, motorcycle)

Contact Lens HistoryHave you ever tried to wear contacts? Yes NoIf not a contact lens wearer, are you interested in trying contacts at this time? Yes NoDo you currently wear contacts lenses? Yes NoType and brand of current contact lenses: rigid, soft, extended wearBrand:How often do you wear your contacts? Hour per day/times per weekAt what point of the day do they get uncomfortable?What colution do you use?Please rate the following on a scale of 1 to 10, with 1 being poor to 10 being excellent:lens comfort R Ldistance vision R Lnear vision R LNS - you have something written... “something I cannot ready” drop

Family Historynote any family history (parents, grandparents, siblings, children; living or deceased) for thefollowing conditions.

Disease/Conditionyes/no (relationship to you)blindness Yes No cataract Yes Nocrossede eyes Yes Noglaucoma Yes Nomacular degeneration Yes Noretinal detachment or disease Yes Noarthritis Yes Nocancer/type Yes Nodiabetes Yes Noheart disease Yes Nohigh blood pressure Yes Nokidney disease Yes Nolupus Yes Nothyroid disease Yes Noother:

Social HistoryThis information is kept strictly con�dential. You may discuss this portion directly with the doctorif you prefer.Yes, I would prefer to discuss my social history information directly with my doctor

Do you drive? Yes NoIf yes, do you have visual di�culty when driving?If yes, please describe:

Do you use tobacco products? Yes NoIf yes, type/amount/how longDo you drink alcohol? Yes NoIf yes, type/amount/how longDo you use illegal drugs? Yes NoIf yes, type/amount/how longDo you drink ca�einated drinks? Yes NoIf yes, what kind, volume and how often?Do you drink sweet drinks? Yes No(e.g., soda, juice,sweetened co�ee/tea)If yes, what kind, volume and how often?Do you engage in regular exercise? Yes NoIf yes, how often? Min/hour per week?Have you ever been exposed to or infected by Gonorrhea Yes NoHepatitis Yes NoHIV Yes NoSyphilis Yes NoWhat are your hobbies/ interests/activiteindoor and outdoorAre you a student? Yes NoIf yes, favorite subject(s)least favorit subjectgrade levelschool distict

Review of SystemsDo you currently, or have you ever routinely had any problems in the following areas?yes/no/explainSystemConstitutional fever, weight loss/gain Yes NoIntegumentary (skin) Yes NoNeurolo�cal Yes Noheadaches Yes Nomigraines Yes Noseizures Yes NoEyesloss of vision Yes Noblurred vision Yes Nodistorted vision/halos Yes Noloss of side vision Yes Nodouble vision Yes Nodryness Yes Nomucous discharge Yes Noredness Yes Nosandy or gritty feeling Yes Noitching Yes Noburning Yes Noforeign body sensation Yes Noexcess tearing/watering Yes Noglare/light sensitivity Yes Noeye pain or soreness Yes Nochronic infection, eye or lid Yes Nosties or chalazion Yes No�ashes, �oaters in vision Yes Notired eyes Yes No

Endocrinethyroid/other glands Yes NoReproductive Yes NoPregnant Yes NoIf yes, weeks alongEars, Nose, Mouth, Throatallergies/hay fever Yes Nosinus congestion Yes Norunny nose Yes Nopost-nasal drip Yes Nochronic cough Yes Nodry throat/mouth Yes NoRespiratory Yes Noasthma Yes Nochronic bronchitis Yes Noemphysema Yes NoVascular/Cardiovascular Yes Nodiabetes Yes Noheart pain Yes Nohigh blood pressure Yes No vascular disease Yes Nohigh cholesterol Yes NoGastrointestinaldiarrhea Yes Noconstipation Yes NoGenitourinary Yes Nogenitals/kidney/bladder Yes NoBones/Joints/Musclesrheumatoid arthritis Yes Nomuscle pain Yes Nojoint pain Yes NoLymphatic/Hematologicanemia Yes Nobleeding problems Yes NoAllergy Yes NoAuto-Immune Yes NoPsychiatricYes NoOther:

If you answered YES to any of the above or have a condition not listed, please explain and listmedications:

Patient Signature/Date Doctor’s Signature/Date

(4 lines for patient signature and date and doctor initial)

Patient Name ______________________________________________________________________________________

Dr. Mr. Mrs. Ms. Preferred Name / Nickname ___________________________________________________________________________________ Address _________________________________________________________________________________________

City _____________________________________________________________ Zip Code ______________________

Primary Phone __________________________________ Secondary Phone _________________________________

Email __________________________________________________________________________________________

Date of Birth _______________________________________ SS# (Last Four Digits Only) ______________________________

Genetic Sex: Pronouns: Male Female He/Him/His She/Her/Hers They/Them/Theirs Other _________________________

Preferred Language________________________________ Race __________________________________________

Occupation _____________________________________________________________________________________

Emergency Contact / Relationship ____________________________________ Phone __________________________

Patient Guardian (If Applicable) ______________________________________ Phone_______________________________

VISON INSURANCE If possible, please bring insurance card to your appointment

Carrier_________________________________________ ID Number ______________________________________ (if you have one, please bring your card to appointment)

If patient is not the primary member on insurance, please provide:

INSURED ‘S NAME ___________________________________________ DOB _______________ SS# (LAST 4 DIGITS ONLY) _______________

Date of Last Eye Exam ______________________________________________________________________________

Doctor/Practice ________________________________________________ Phone_____________________________

HEALTH INSURANCE Please bring insurance card to your appointment

Carrier_________________________________________ ID Number ______________________________________ (if you have one, please bring your card to appointment)

If patient is not the primary on insurance, please provide:

INSURED ‘S NAME ___________________________________________ DOB _______________ SS# (LAST 4 DIGITS ONLY) _______________

Date of Your Last Medical Exam ________________________________________________________________________

Doctor /Practice ______________________________________________ Phone ____________________________

DATE ___________________________________________

PATIENT INFORMATION FORMPAGE 1

MEDICAL HISTORY

Do you have any allergies to medications? No Yes: ___________________________________________________

List any medications you take and what conditions you take them for (including eyedrops, oral contraceptives,pain medication, over the counter medications, home remedies, vitamins):

List all major surgeries and/or hospitalizations you have had and when: _________________________________________

Check any of the following that you have had:

crossed eyes lazy eye drooping eyelid

Describe further: _______________________________________________________________________________________

SPECTACLES HISTORY

Do you wear glasses? Yes No If yes, how old is your current prescription? ______ Do you use them full time part time

CONTACT LENS HISTORY If not a contact lens wearer, are you interested in trying contacts at this time? No Yes

Do you currently wear contacts? No Yes: Type: rigid scleral soft extended wear If yes, what brand? _________________________________________________________________________________________

How often do you wear your contacts: Hours per day ___________________ Times per week ___________________

What kind of contact solution do you use? _______________________________ Do you use arti�cial tears? No Yes

Please rate the following on a scale of 1 to 10 (with 1 being poor to 10 being excellent): LENS COMFORT______________ DISTANCE VISION______________ NEAR VISION______________

At what point of the day do they get uncomfortable? _______________________________________________________

cataracts eye injury eye surgery

prominent/bulging eyes dry eye glaucoma

retinal detachment macular degeneration eye infections

bifocals/trifocals/progressives computer/o�ce occupational / safety

back up/emergency glasses sun If yes, are they prescription sunglasses? Yes sports

PAGE 2

____________________________________________________________________________________________________

_____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Check the types of Glasses you use:

close / reading far / distance bifocals/trifocals/progressives

REVIEW OF SYSTEMSDo you currently, or have you ever routinely had any problems in the following areas?

CONSTITUTIONAL fever, weight loss/gain............Yes NoIntegumentary (skin)...............Yes NoNeurological.................................Yes Noheadaches....................................Yes Nomigraines......................................Yes Noseizures..........................................Yes No

EYESloss of vision................................Yes Noblurred vision..............................Yes Nodistorted vision/halos..............Yes Noloss of side vision.......................Yes Nodouble vision..............................Yes Nodryness..........................................Yes Nomucous discharge.....................Yes Noredness..........................................Yes Nosandy or gritty feeling..............Yes Noitching............................................Yes Noburning.........................................Yes Noforeign body sensation...........Yes Noexcess tearing/watering.........Yes Noglare/light sensitivity................Yes Noeye pain or soreness.................Yes Nochronic infection, eye or lid...Yes Nostyes or chalazion...................... Yes No�ashes/�oaters in vision.........Yes Notired eyes......................................Yes No

ENDOCRINEThyroid/other glands.....Yes NoReproductive.....................Yes NoPregnant Currently..............Yes NoIf yes, how many weeks along: ____

EARS, NOSE, MOUTH, THROAT allergies/hay fever............Yes Nosinus congestion..............Yes Norunny nose.........................Yes Nopost-nasal drip..................Yes Nochronic cough...................Yes Nodry throat/mouth............Yes No

RESPIRATORYasthma.................................Yes Nochronic bronchitis............Yes Nosleep apnea........................Yes No emphysema.......................Yes No

VASCULAR/CARDIOVASCULAR diabetes......................................................heart pain............................high blood pressure.........vascular disease.................high cholesterol.................heart attack .........................stroke ...................................

BONES/JOINTS/MUSCLESrheumatoid arthritis..................Yes Nomuscle pain..................................Yes Nojoint pain.......................................Yes No

LYMPHATIC/HEMATOLOGICanemia.............................................Yes Nobleeding problems.......................Yes No

ALLERGIES.........................................Yes No

AUTO-IMMUNE..............................Yes No

PSYCHIATRIC....................................Yes No

GASTROINTESTINALInfammatory Bowel Disease......Yes No diarrhea............................................Yes Noconstipation.....................................Yes Nogenitals/kidney/bladder.............Yes No

OTHER OR EXPLANATIONS:___________________________________________________________________________________________________

PAGE 3

No YesNo YesNo YesNo YesNo YesNo Yes

No YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo Yes

No YesNo YesNo Yes_______

No YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo Yes

No YesNo YesNo YesNo YesNo YesNo YesNo Yes

No YesNo YesNo Yes

No YesNo YesNo Yes

No Yes

No Yes

No Yes

No YesNo YesNo YesNo Yes

blindness .............................. ______________________________________________________________________________________________________

cataract ................................. ________________________________________________________________________________________________

crossed eyes ........................ _________________________________________________________________________________________glaucoma ............................. ________________________________________________________________________________________macular degeneration ..... ______________________________________________________________________________________retinal detachment .......... _________________________________________________________________________________________arthritis ........................................_________________________________________________________________________________________auto immune disease ..........________________________________________________________________________________________cancer ..................................... ________________________________________________________________________________________diabetes ................................ _________________________________________________________________________________________heart disease ......................._______________________________________________________________________________________high blood pressure .......... ______________________________________________________________________________________high cholesterol ........................................________________________________________________________________________________thyroid disease .......................________________________________________________________________________________________stroke ......................................................___________________________________________________________________________________ other ......................................................___________________________________________________________________________________

To what? _____________________________________________________

No YesNo YesNo YesNo YesNo YesNo YesNo YesNo Yes

No YesNo YesNo YesNo YesNo YesNo YesNo YesNo Yes

If yes, which relatives?

FAMILY HISTORYNote any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions:

indoor __________________________________________ outdoor ___________________________________________

SOCIAL HISTORY

This information is kept strictly con�dential. Check this box if you prefer to discuss this portion directly with the doctor: YES I would prefer to discuss my social history information directly with my doctor

Do you drive? No YesIf yes, do you have visual di�culty when driving? No Yes: please describe: ______________________________________________

Do you use tobacco products? No Yes: type/amount/number of years? ___________________________________________

Do you drink alcohol? No Yes: type/amount/number of years? ___________________________________________________

Do you use illegal drugs? No Yes: type/amount/number of years? _________________________________________________

Do you drink ca�einated drinks? No Yes: what kind, volume and how often? ______________________________________

Do you drink sweet drinks? No Yes: what kind, volume and how often? ____________________________________________e.g., soda, juice, sweetened co�ee/tea)

Do you engage in regular exercise? No Yes: what kind(s)? how often? Min/hour per week?

_______________________________________________________________________________________________________________

What are your hobbies/ interests/activites:

Are you a student? No Yes: what grade level / school ? ___________________________________________________

Have you ever been exposed to or infected by: Gonorrhea......... Hepatitis............ HIV....................... Syphilis ............. Chlamydia.........

Review of SystemsDo you currently, or have you ever routinely had any problems in the following areas?yes/no/explainSystemConstitutional fever, weight loss/gain Yes NoIntegumentary (skin) Yes NoNeurolo�cal Yes Noheadaches Yes Nomigraines Yes Noseizures Yes NoEyesloss of vision Yes Noblurred vision Yes Nodistorted vision/halos Yes Noloss of side vision Yes Nodouble vision Yes Nodryness Yes Nomucous discharge Yes Noredness Yes Nosandy or gritty feeling Yes Noitching Yes Noburning Yes Noforeign body sensation Yes Noexcess tearing/watering Yes Noglare/light sensitivity Yes Noeye pain or soreness Yes Nochronic infection, eye or lid Yes Nostyes or chalazion Yes No�ashes, �oaters in vision Yes Notired eyes Yes No

Endocrinethyroid/other glands Yes NoReproductive Yes NoPregnant Yes NoIf yes, weeks alongEars, Nose, Mouth, Throatallergies/hay fever Yes Nosinus congestion Yes Norunny nose Yes Nopost-nasal drip Yes Nochronic cough Yes Nodry throat/mouth Yes NoRespiratory Yes Noasthma Yes Nochronic bronchitis Yes Noemphysema Yes NoVascular/Cardiovascular Yes Nodiabetes Yes Noheart pain Yes Nohigh blood pressure Yes No vascular disease Yes Nohigh cholesterol Yes NoGastrointestinaldiarrhea Yes Noconstipation Yes NoGenitourinary Yes Nogenitals/kidney/bladder Yes NoBones/Joints/Musclesrheumatoid arthritis Yes Nomuscle pain Yes Nojoint pain Yes NoLymphatic/Hematologicanemia Yes Nobleeding problems Yes NoAllergy Yes NoAuto-Immune Yes NoPsychiatricYes NoOther:

If you answered YES to any of the above or have a condition not listed, please explain and listmedications:

PAGE 4

Herpes................................Chicken Pox / Shingles....SARS/COVID .......................MRSA .....................................Fungal Infection.................

PLEASE SIGN:

PATIENT SIGNATURE ___________________________________________________ DATE ____________________________

DOCTOR SIGNATURE ___________________________________________________ DATE ____________________________

No Yes ___________________No Yes ____________________No Yes ____________________No Yes ____________________No Yes ____________________

No Yes ____________________No Yes ____________________No Yes ____________________No Yes ____________________No Yes ____________________

favorite subject(s) _______________________________ least favorite subject(s) _______________________________