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SELECT A PRACTITIONER
Doctor*
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Optometrist, Doctor Kunle Oluwadare, O.D.,M.S.
Optometrist, Doctor Rajan Thomas O.D.
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PERSONAL
Prefix*
Mr.
Mrs.
Ms.
Miss
Dr.
Fr.
First Name*
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Last Name*
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Address*
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Address 2
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City*
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State* / Zip*
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Home Phone*
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Day Phone
Cell Phone
Pager
Fax
Email*
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Gender*
Male
Female
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Date of Birth* (mm/dd/yyyy)
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SS# (no dashes)
Marital Status
Divorced
Legally Separated
Married
Single
Widowed
Other
Employment
Employed Full-Time
Employed Part-Time
Not Employed
On Active Military Duty
Retired
Self-Employed
Student Full-Time
Student Part-Time
Other
Employer
Occupation
How were you referred to our office?*
Friend or Family
Family Doctor
Ophthalmologist
Insurance Company
Internet
Driving By
Newspaper
Television
Radio
Received Mailing
Internet
Other Optometrist
Other »
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EYE HISTORY
Please check any current conditions you suffer from.
I stopped wearing glasses because:
I stopped wearing contact lenses because:
Headaches
Glare/Light Sensitivity
Tired Eyes
Amblyopia (lazy eye)
Burning
Dryness
Watery Eyes
Eye Pain and/or Soreness
Foreign Body Sensation
Infection of Eye or Lid
Itching
Mucous Discharge
Drooping eyelid(s)
Redness
Sandy or Gritty Feeling
Strabismus (crossed eye)
Blurred Vision at Distance
Blurred Vision at Near
Haloes
Double Vision
Floaters or Spots
Fluctuating Vision
Loss of Vision
Loss of Side Vision
GLASSES HISTORY (skip if you don't wear glasses)
What Glasses do you own?
Single Vision
Bifocals
Safety Glasses
Backup Glasses
Progressive
Trifocals
Sports Glasses
Sunglasses
Other
How many hours a day do you use a computer?
How many inches away, approximately, do you sit from your computer monitor?
Please check off any current conditions you suffer from.
I am having problems with my current glasses
There are times when I would rather not be wearing glasses
I have problems with glare
I have problems with night vision
I am allergic to nickel (e.g. frames of glasses)
I don’t have spare set of glasses
My spare glasses have an incorrect prescription
My sunglasses are missing UV (ultra-violet) protection
CONTACT LENS HISTORY (skip if you don't wear contacts)
What brand of contact lenses do you wear?
How old are your current lenses?
How often do you replace or dispose of your contact lenses?
What brand of solution do you soak your lenses in?
What is your typical wearing schedule?
Hours per day:
Days per week:
Please check off all that apply to you:
I am having problems with my current contact lenses
There are times when I would rather not be wearing contact lenses
I am interested in changing or enhancing my eye color
I am interested in a non-surgical method of vision correction
I am interested in refractive laser surgery
I don't have a spare set of contact lenses
My spare contact lenses have an incorrect prescription
MEDICAL HISTORY
When, approximately, was your last eye exam?
Where did you get your last eye exam?
When, approximately, was your last physical exam?
Do you drink alcohol?
No
Yes, 1 per day
Yes, 2 - 3 per day
Yes, 4+ per day
Do you smoke?
No
Yes, 1/2 pack per day
Yes, 1 pack per day
Yes, 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:
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Please check off any current conditions you suffer from:
Chronic fever, unexpected weight loss/gain, fatigue
Ear/nose/throat
problems ( eg. Hearing loss, sinus problems, sore throat)
Heart problems
(eg. Chest pain, irregular heart beat, swelling of feet, cold
hands or feet)
Respiratory problems (eg. Shortness of breath, wheezing, coughing)
Gastrointestinal
problems (eg. Heartburn, abdominal pain, diarrhea, vomiting)
Genitourinary
problems (eg. Painful urination, blood in urine, sex organ problems)
Musculoskeletal
problems (eg. Muscle aches, joint pain, swollen joints)
Skin problems
(eg. Rashes, excessive dryness, growths or lumps)
Neurological problems
(eg. Numbness, weakness, headaches, “blackouts”)
Psychiatric
problems (eg. Depression, anxiety)
Endocrine problems (eg. Frequent
urination, thirst, feeling hot or cold all
the time)
Blood/Lymph problems (eg. Bruising, weakness, unusual paleness,
swollen glands)
Immune problems (eg. Frequent infections, allergic
reactions to foods, dust, pollens)
PRIMARY INSURANCE
Please bring all insurance cards to your appointment.
Insurance Company
Phone Number
Address
Insured's Name
ID Number
Group Number
Insured's Date of Birth
Insured's SS#
Patient's Relationship to insured
SECONDARY INSURANCE
Please bring all insurance cards to your appointment.
Insurance Company
Phone Number
Address
Insured's Name
ID Number
Group Number
Insured's Date of Birth
Insured's SS#
Patient's Relationship to insured
HIPAA PRIVACY POLICY
Health Information Protection*
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