Adult History Form

WELCOME TO ENVISION EYECARE

We appreciate you choosing us for your professional eye care.

Salutation
Last Name*
First Name*
Middle Initial
Today's Date
Nickname
Status
Home Address
Date of Birth
City
State
Zip
Home Phone
Cell Phone
Work Phone
Email
Preferred Phone Number
Race
Preferred Language
Have we taken care of your family members? If yes, whom?
May we thank someone for referring you? If yes, whom?
Medical Insurance
Vision Insurance
Front of Insurance Card
Back of Insurance Card
Policy holder's name
Policy holder's employer
Social Security Number

LIFESTYLE QUESTIONNAIRE
This will allow us to make recommendations for your specific eye care needs!

What is the Reason(s) for your visit today?
When was your last eye exam?
Are you having vision problems without glasses?

Glasses

Do you wear glasses? If no, skip to the contact lenses section.
Are you having problems with your glasses?
Are you interested in getting new glasses?
Do your glasses have an anti-glare lenses?
Do you have prescription sunglasses?
Do you have computer glasses?

Lenses
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Do you wear contact lenses?
If no, do you want to try them today?
Are you interested in colored contacts?

Refractive Surgery
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Are you interested in laser surgery?

Activities
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Employer
Occupation
Is it difficult to see when driving during the day?
At night?
How many hours per day do you use the computer?
Do you spend time outdoors?
How many hours per week?
What hobbies do you enjoy?
Do these activities strain your eyes?

Social History
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Please check the box if you prefer to discuss the following information with the doctor only.

Do you use tobacco products?

Do you drink alcohol?

If yes, type / amount / how long:

Do you use illegal drugs?

If yes, type / amount / how long:

Ocular History
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Do you have any eye problems?

Medical History
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Name of Medical Doctor
Last Medical Exam
Medications
Do you have any allergies?
If yes, please list.
List all major injuries, surgeries and/or hospitalizations
Are you pregnant?
Are you nursing?

Review of Systems - Please check all that apply or fill in the blank for those not listed.
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Constitutional
Ears, Nose, Throat
Neurological
Psychiatric
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary
Endocrine
Hematologic / Lymphatic
Allergic / Immunologic

Family History
List the family member(s) that has/had the following: (Ex. Mother, Grandparent, etc)

Heart Disease
High Blood Pressure
Diabetes
Cancer
Thyroid Disease
Cataract
Glaucoma
Macular Degeneration
Lazy Eye / Amblyopia
Eye Turn / Strabismus
Nystagmus
Retinal Detachment / Disease
Arthritis
Lupus
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