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EyeWorks Patient Information
Last Name:
First Name:
Gender: Male
Female
Title:
Street Address:
City:
State:
Zip:
Phone:
Work Phone:
SSN:
Employer:
Referred by:
Insurance Information
Subscriber's Last Name:
Subscriber's First Name:
Street Address:
City:
State:
Zip:
Subscriber's SSN:
Subscriber's Birthdate(0/0/00):
Subscriber's Employer:
Relationship to Patient:
Vision Insurance Name:
ID#:
Plan/Grp #:
Medical Insurance Name:
Plan/Grp #:
Medical History
Most recent medical exam:
date: 		 Primary Care Physician:
Most recent visual exam:
date: 		 Eye Doctor:
Medications currently used and condition being treated (including birth control):
Have you ever been diagnosed at HIV positive? yes   date:
no
Do you have any allergy or sinus problems? (describe):
Do you or your family have a history of the following?
High Blood Pressure  
Diabetes  
Thyroid  
Cancer  
Glaucoma  
Cataracts  
Blindness  
Hepatitis  
Complete Eye Health and Vision Histories will be taken by a member of our staff during the pretest portion of your examination.
Lifestyle Questions
What is closest to your occupation? Office   Mechanic   Sales   Construction  

Medical   Driving  
Computer Field  

What are your hobbies? Sports   Fishing, Hunting  
Sewing, Needlework  
Computer  
Music   Driving   

Other  

What brands of eyewear are you interested in? Fendi   Coach   Dior  
Rudy Project   Nike  
Kate Spade   Gucci  
Armani   Maui Jim  
Are you sensitive to light?
yes no
Do you have trouble reading?
yes no
Is night driving uncomfortable?
yes no
Do you have trouble with glare from the sun?
yes no
Do you have any special visual needs?
yes no