Creative Optical > New Patients > 2011 CREATIVE OPTICAL, LLC

First Name:

Last Name:

Date:

Select Date

Date of Birth:

Date of last Eye exam :

List any medications you currently take (RX and over the counter):

Do you have allergies to any medications?:

Yes
No

If YES, list the medications:

List all major illnesses (glaucoma, diabetes, high blood pressure, heart attack, etc.)or injuries:

List any surgeries you have had (cataract, appendectomy):

Do you currently have any problems in the following areas? If YES, please provide additional information.:

EYES (Poor vision, eye pain, tearing, redness, etc.):

Yes
No

EYES Details:

GENERAL / CONSTITUTIONAL(fever, heat stroke, weight loss, weight gain, unusually tired, etc.):

Yes

No

GENERAL / CONSTITUTIONAL Details:

EARS, NOSE, THROAT (hard of hearing, stuffy nose, earache, cough, dry mouth, etc.):

Yes
No

EARS, NOSE, THROAT Details:

CARDIOVASCULAR (high BP, racing pulse, etc.):

Yes
No

CARDIOVASCULAR Details:

RESPIRATORY (congestion, wheezing, short of breath etc.):

Yes

RESPIRATORY Details:

GASTROINTESTINAL (stomach upset, diarrhea, constipation, hernia, ulcers, etc.):

Yes
No

GASTROINTESTINAL Details:

GENITAL, KIDNEY, BLADDER (painful urination, frequent urination, impotence, yellow jaundice, etc.):

Yes
No

GENITAL, KIDNEY, BLADDER Details:

FEMALES Are you pregnant? Nursing?:

Yes
No

FEMALES Details:

MUSCLES, BONES, JOINTS (joint pain, stiffness, swelling, cramps, arthritis, etc.):

Yes
No

MUSCLES, BONES, JOINTS :

SKIN (pimples, warts, growths, rash, etc.):

Yes
No

SKIN Details:

NEUROLOGICAL (numbness, headaches, seizures, paralysis, etc.):

Yes
No

NEUROLOGICAL Details:

PSYCHIATRIC (anxiety, depression, insomnia, etc.):

Yes
No

PSYCHIATRIC Details:

ENDOCRINE (diabetes, hypothyroid, etc.):

Yes
No

BLOOD / LYMPH (bleeding, cholesterolemia, anemia, problems related to blood transfusion, etc.):

Yes
No

BLOOD / LYMPH Details:

ALLERGIC / IMMUNOLOGIC (sneezing, swelling, redness, itching, hives, lupus, etc.):

Yes
No

ALLERGIC / IMMUNOLOGIC :

FAMILY HISTORY:

(Mother, Father, Grandparent, Sibling):

Has any member of your family had these diseases (circle all that apply)? :

Blindness
Cataract
Diabetes
Glaucoma
Hypertension
Heart Disease
Stroke
Cancer
Thyroid Disease
Arthiritis

Other heritable disease:

SOCIAL HISTORY:

Does your vision limit any activities of daily living (driving, reading, sports, work, etc.)?:

Yes
No

Are you interested in Lasik Surgery?:

Yes
No

Have you ever had a blood transfusion? :

Yes
No

Do you drink alcohol? :

Yes
No

IF YES, how much? :

Do you smoke? :

Yes
No

Smoking If YES, how much? :

Smoking How Many Years? :

Physician’s Signature:

Date: