PATIENT INFORMATION

                                              Date_________________       Sex:   _______M     _____F

Name_______________________________________________________________________

Age______Date  Of Birth___________ Soc. Sec. Number:_____________________________

Address_________________________City___________State______________ Zip__________

Home Phone:________________ Work Phone:___________________ Marital Status:________

School/Grade (if student)_____________________ Employer____________________________

Spouse or Parents Name ________________________________________________________

Do you use a computer?  Yes___ No___ Do you experience any of the following while working on computer?  

___Eye Strain     ___Headaches    ___Eye Pain   ___Burning Tired Eyes ___

New Patient   ___   Previous Patient ___      Do You Wear Glasses? ___Yes ___No

Do you want to be examined for contacts today? ___Yes ___No    Have you ever worn contacts? __Yes __No

Are you interested in discussing Lasik type refractive surgery  today?   Yes_____ NO ______

When was your last eye exam? __________  Doctor’s Name? ___________________________

How old are your current glasses? ____________ How old are your current contacts?_________

Have you ever had any eye injury? _______ Eye surgery? _____  Had to take eye meds? _____

    If so, please explain:_____________________________________________________________                        

   Are you being or have you ever been treated for the following ?  Please check all that apply.        

   ___High Blood Pressure         ___Diabetes                  ___Heart Condition       ___Arthritis _

   ___ Thyroid                           Blood Sugar______        ___Seizures                  ___Headaches

   ___Allergies                          Last Taken on_____      ___Cancer                     ___Blood Disorder

   ___Kidney                             ___Stomach/Intestine    ___Glaucoma                ___Pregnancy

   ___Use Tobacco                   ___Skin Condition          ___Nerve Condition

  Other______________________________________________________________________

  List any known allergies:__________________________________________________________

  Do any of your blood relatives have any of the listed conditions?  Please check all that apply.

  ___High Blood Pressure          ___Diabetes                  ___Heart Condition        ___Migraine HA

  ___Glaucoma                          ___Cataracts                 ___Crossed/Lazy Eye    ___Eye Disease

  ___Blindness                         Other:__________________________________________________

Have your eyes ever been dilated?_________ Any adverse reaction? _________

Other pertinent information ___________________________________________________________

_________________________________________________________________________________

 Who may we thank for referring you? ________________________________________________

  CONSENT:  I give PRECISION OPTICAL all authority necessary to perform diagnostic and

  Therapeutic procedures for my best ocular health.  This includes dilation, that may produce side

  effects or allergic reactions.  PLEASE SIGN BELOW.  If under 18, parent or guardian must sign.

X____________________________________

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