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1、VISION MAX - BAYTOWNAccount No. _New or UpdatedPATIENT INFORMATION Thank you for choosing our practice for your eyecare needs.Please complete this form (BOTH PAGES) in ink. If you have any questions or concerns, do not hesitate to ask for assistance. We will be happy to help.(PLEASE PRINT) Date _Nam
2、e _(Mr., Mrs., Ms., Dr.) First MI Last NicknameAddress _ Apt. No. _City _State _ Zip _ Home Phone No. _ Work Phone No. _ Ext. _Date of Birth _ Age _ Sex _ Occupation_ (MM/DD/YYYY) (M/F)Employer/School _ Hobbies _REFERRED BY: (Circle one please): Family Friend Doctor Yellow Pages Newspaper Coupon Wal
3、k-In Radio TV Recall Letter Other _RESPONSIBLE PARTYName of person responsible for this account_Relationship to Patient _ Contact Phone No. _Address _ Apt. No. _ City _State _ Zip _ Employer _ Work Phone No. _ Ext. _Drivers License No. _ Method of payment: Cash_ Check_ AMEX_ Visa_ MC_ (State-#) Disc
4、over_ VISION INSURANCE INFORMATIONName of Vision Plan _Group Number _Name of Insured _ Relationship to Patient _Date of Birth of Insured _Insured Social Security Number or Member ID Number _IMPORTANT HEALTH HISTORYReason for todays exam _Date of last exam _Name of last eye doctor_Please list all sur
5、geries _Please list all drug allergies _Please list all medications you are currently taking _Continued on next page REVIEW OF SYSTEMS Please check all health problems that apply to you:EyesBlindness _ Loss of vision _ Distorted vision _ Blurred vision _ Double vision _ Cataracts _ Crossed eyes _ Fl
6、ashes or floaters _ Dry eyes _ Watery eyes _ Red eyes_ Mucous discharge_ Burning or itching_ Sandy or gritty feeling_ Eye pain or soreness_ Glare/Light Sensitivity_ Chronic eye infections_ Tired eyes_ Halos_ Vision therapy_ Eye surgery_ Eye injury_ Retinal detachment_ Glaucoma_Allergic/ImmunologicHa
7、y fever_ Medicine allergies_ Constitutional symptomsFever_ Weight loss_CardiovascularHeart pain_ High blood pressure_ Vascular disease_Ears, Nose, Mouth, ThroatAllergies/Hay fever_ Sinus problems_ Chronic cough_ Dry throat/mouth_ Chronic ear infections_EndocrineThirsty all the time_ Frequent urinati
8、on_ Diabetes_ Thyroid problems_ Other glands_GastrointestinalDiarrhea_ Constipation_ Ulcers_GenitourinaryGenitals_ Kidneys_ Bladder_Hematologic/LymphaticAnemia_ Bleeding problems_ Swelling_IntegumentarySkin_ Breast_MusculoskeletalArthritis_ Rheumatoid Arthritis_ Muscle pain_ Joint pain_NeurologicalH
9、eadaches_ Migraines_ Seizures_PsychiatricNervous disorders_ Depression_ Compulsive behavior_RespiratoryAsthma_ Shortness of breath_ Emphysema_ Lung cancer_Does anyone in your family have a history of the following?_Cataracts _Thyroid _Arthritis _Blindness _Turned or Lazy Eye _High Blood Pressure _Gl
10、aucoma _Heart Condition _DiabetesPlease CHECK any of the following that apply to you or (N) for none:_Frequent Headaches _Allergies _Pregnant _Sinus Trouble _Drug Allergies _Given birth in the last 6 monthsDo you currently wear glasses? _Y _N Do you work at a computer or video display terminal? _Y _N If yes, how many hours? _When do you wear your glasses?_All the time _Reading/Near work _Work Safety _distance task only _Computer work_other (please explain)_
