Primary Care Physician Name *

First Name

Last Name

Phone

(###)

###

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Referring Physician Name

First Name

Last Name

Phone

(###)

###

####

Your Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone *

(###)

###

####

Mobile Phone

(###)

###

####

Work Phone

(###)

###

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Spouse Name

First Name

Last Name

Spouse Phone

(###)

###

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How did you hear about us?

Check all that apply. If other, please specify below.

Physician Referral

Patient Referral

Online Ad

Google Search

yp.com (Yellow Pages)

Insurance

Other

Are you or have you used any medication(s) for the following type of conditions?

Check all that apply.

Inflammatory Disease

Prostate Problems

Urinary Problems

Acne

What type of contacts are you using?

Soft

Extended Wear

Daily

Monthly

Hard/Gas Perm

General

Difficulty Sleeping

Drowsiness/Fatigue/Malaise

Poor Appetite

Weight Loss/Gain

Sjogren's Syndrome

Sarcoidosis

Systemic Lupus Erythematosus (SLE)

Other

Eyes

Loss of Vision

Blurred Vision

Distorted Vision/Halos

Loss of Side Vision

Double Vision

Dryness

Mucous Discharge

Redness/Bloodshot

Sandy or Gritty Feeling

Itching

Burning

Foreign Body Sensation

Excess Tearing/Watering

Glare/Light Sensitivity

Pain or Soreness

Chronic Infection of Eye or Lid

Styes or Chalazion

Flashes/Floaters/Spots in Vision

Tired Eyes

Other

Cardiovascular

High Cholesterol

Heart Attack/Angina (chest pain)

Pacemaker/Heart Disease

Heart Murmur/Arrhythmia/Hypertension

Congestive Heart Failure (CHF)

Arteriosclerotic Cardio Disease (ASCVD)

Carotid Artery Disease (CAD)

Coronary Artery Bypass Grafting (CABG)

Artial Fibrillation Arrhythmia (AFib)

Varicose Veins/Stent(s)

Blood Clot(s)

Other

Ear, Nose & Throat

Presbycusis/Tinnitus/Vertigo

Ear Infections/Sinusitis

Swollen Lymph Nodes

Sore Throat/Voice Change

Other

Endocrine

Pre/Borderline Diabetic

Non-Insulin Diabetic

Insulin Diabetic

Hypothyrodism/Hyperthyrodism

Excessive Thirst or Urination

Graves' Disease/Goiter

Other

Musculoskeletal

Joint/Neck/Back Pain

Muscle Aches/Weakness

Arthritis/Gout/Fibromyalgia

Rheumatoid Arthritis

Leg Cramps

Decreased Range of Motion (ROM)

Other

Neurological

Neuropathy/Stroke

Multiple Sclerosis (MS)

Transient Ischemic Attacks (TIA)

Seizures/Paralysis

Headaches/Migraines/Tremors

Mental Retardation

Parkinson's Disease

Alzheimer's/Dementia

Other

Psychiatric

Depressed Mood/Manic Depression

Suicidal Thoughts

Panic Attacks/Anxiety

Mood Swings/Bipolar Disorder

Schizophrenia

Other

Gastrointestinal

Constipation/Diarrhea

Diverticulitis/Cramps

Change in Bowel Movements

Irritable Bowel Syndrome (IBS)

Acid Reflux/Difficulty Swallowing

Stomach Ulcers

Hepatitis/Liver/Colon/Crohn's Disease

Other

Genitourinary

Frequent Urination

Difficulty Urinating

Blood in Urine/Stool

Kidney Stones/Failure

Enlarged Prostate/Incontinence

Gonorrhea

HIV

AIDS

Syphilis

I prefer to discuss STDs with doctor

Frequent Infection: Bladder/Yeast

Other

Hematological/Lymphatic

Easy to Bruise/Bleed

Anemia/Leukemia/Sickle Cell

Phlebitis/Thrombosis

Transfusion

Other

Skin Changes

Rash/Itching/Dry Skin

Psoriasis/Rosacea

Tags/Acne

Lupus (Discoid)

Other

Respiratory

Asthma/Bronchitis

Wheezing/Shortness of Breath

Emphysema

Tuberculosis (TB)

Chronic Obstructive Pulmonary (COPD)

Other

Family History

Check all symptoms that apply to your family history.

Blindness

Crossed Eyes

Macular Degeneration

Arthritis

Heart Disease

Kidney Disease

Thyroid Disease

Cataracts

Glaucoma

Retinal Detachment

Diabetes

High Blood Pressure

Lupus

Cancer (Describe Type Below)

Other

Patient Signature

Please type your name and the date below. This will act as your digital signature.

First Name

Last Name

Date

MM

DD

YYYY