Patient History Form

Name: Complete Eye Care
Address: 1200 Spruce Street, Belmont, NC, 28012, US
Telephone: 704-825-9002
Price range: $000 - $300

WELCOME TO OUR OFFICE
Please help us provide you the best possible care by providing the following information.
Name
First Last
Today's Date
Date Format: MM slash DD slash YYYY
Nickname
E-mail Address
Address
Street City State Zip
Home Phone
Work Phone
Cell Phone
Social Security Number
Employer
Occupation
Date of Birth
Date Format: MM slash DD slash YYYY
Age
Sex
Date of Last Exam
Date Format: MM slash DD slash YYYY
What is the major purpose of this visit?
Spouse’s Work Phone
Any Problems with your present contact lenses or glasses?
Spouse’s Name
First Last
Parents Work Phone
(If child)
Mother’s and Father’s Name
(If child)
Mother's Name Father's Name
Do you participate in a flexible spending account?
- Yes
- No
Vision Insurance
How will you settle your account today?
- Check
- Cash
- Credit Card
MEDICAL HISTORY
Yes No
Allergies
Arthritis
Asthma
Cancer
Diabetes
Eye Injury
Eye Disease
Heart Disease
High Blood
Lazy Eye
Eye Surgery
Cataracts
Lung Condition
Glaucoma
Thyroid
Other
If other, please specify:
CURRENT MEDICATIONS
Please list all current medications including over the counter meds.
Are you currently under the care of a physician?
- Yes
- No
Name of Physician
FAMILY MEDICAL HISTORY
Blindness
- Yes
- No
Relationship
Cataracts
- Yes
- No
Relationship
Glaucoma
- Yes
- No
Relationship
Diabetes
- Yes
- No
Relationship
Macular Degeneration
- Yes
- No
Relationship
Eye Disease
- Yes
- No
Relationship
Do You...
Work at a computer for long periods?
- Yes
- No
Are there times you’d rather not wear glasses?
- Yes
- No
Wear Bifocals?
- Yes
- No
Have problems with eye glasses scratching?
- Yes
- No
Want information on thinner, lighter lenses?
- Yes
- No
Want information on Corneal Molding?
(a nonsurgical way to get rid of contacts and glasses)
- Yes
- No
Have spare glasses in case yours break?
- Yes
- No
Have prescription sunglasses?
- Yes
- No
Spend time outdoors?
- Yes
- No
How much?
Hrs./week
Have problems with glare or reflection, particularly when driving at night?
- Yes
- No
Have you ever worn/are you currently wearing contacts?
- Yes
- No
What Kind?
Solutions Used?
Interested in a free in-office contact lens trial?
- Yes
- No
List Hobbies
Do You Experience...
- Any discomfort
- Dryness
- Eyes that Burn
- Floaters or Flashes of Light
- Sensitivity to light
- Uncomfortable Contact Lenses
- Headaches
- Itchy Eyes
- Sudden Loss of Vision
- Uncomfortable Glasses
- Double Vision
- Other
If other, please specify:
How did you first hear about our office?
- Friend or Relative
Who?
- Another Health Care Practitioner
Who?
- Mailing
Which?
- Employer
Which?
- Civic Group/Community Event
Which?
- Yellow Pages
Which Directory?
- Newspaper Advertisement
- Other
If Other, please specify:

Due to COVID-19, our office is closed for all routine eye care services. We will be seeing emergency eye care needs only. We have staff answering phones during limited hours. If you have less than a 3 month supply of contact lenses, please contact us at 704-825-9002 and we will help with your contact lens needs. Thank you and stay well!

Patient History Form

WELCOME TO OUR OFFICE

MEDICAL HISTORY

CURRENT MEDICATIONS

FAMILY MEDICAL HISTORY

Do You...

Do You Experience...

How did you first hear about our office?

Follow Us

Complete Eye Care

Reviews

	Yes	No
Allergies
Arthritis
Asthma
Cancer
Diabetes
Eye Injury
Eye Disease
Heart Disease
High Blood
Lazy Eye
Eye Surgery
Cataracts
Lung Condition
Glaucoma
Thyroid
Other