Southlands Vision Patient Form

Southlands Vision Associates

Fill out your medical information carefully
Patient Information

First NameLast Name
First Name*
Middle Name*
Last Name*
SS#
Gender

MaleFemale
Marital Status

MarriedSingleWidow
Birth Date

MonthDayYear
Age
Home Phone

Area CodePhone Number
Day Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
E-mail
Preferred Method of Contact

Home PhoneDay PhoneCell PhoneText (Must provide cell number above)Email
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Occupation
Employer
Hobbies/Special Needs
How did you hear about our office?

Prior PatientDrive-byInsuranceInternetFriend/FamilyLensCrafters Advertising
Party Responsible for Account
Name

First NameLast Name
Home phone

Area CodePhone Number
Cell phone

Area CodePhone Number
Relationship to patient

SelfSpouseParent/Guardian
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date

MonthDayYear
Primary Reason for Visit Today
Check any

Blurred Distance VisionBlurred Near VisionBlurred Intermediate VisionEye Irritation/discomfortEye Infection/DischargeSeeing flashes of lightHaving headaches related to visionSeeing floaters/changes to floaters
List any other reason for your visit
Do you wear glasses

NoYesPrior
If worn, for what purpose?

FarNearComputerAll distancesFull timePart time
Do you wear contacts

NoYesPrior
If worn, brand/powers?
Do you sleep in them?

YesNo
If you do not wear contact lenses, are you interested?

YesNoMaybe (would like to discuss)
Date of last exam and doctor
Date of last physical
Medical History

For each line please indication Self and/or Family and give details/list relation
Amblyopia/Lazy Eye*

NoYes
If yes, please indicate whether self and/or family and give details/list relation.
Strabismus/Turned Eye*

NoYes
If yes, please indicate whether self and/or family and give details/list relation.
Dry Eye Syndrome/Symptoms*

NoYes
If yes, please indicate whether self and/or family and give details/list relation.
Eye Surgery or Therapy (Type)*

NoYes
If yes, please indicate whether self and/or family and give details/list relation.
Eye Injury (type, timeline, status)*

NoYes
If yes, please indicate whether self and/or family and give details/list relation.
Macular Degeneration*

NoYes
If yes, please indicate whether self and/or family and give details/list relation.
Glaucoma*

NoYes
If yes, please indicate whether self and/or family and give details/list relation.
Retinal Detachment/ Hole/ Repair*

NoYes
If yes, please indicate whether self and/or family and give details/list relation.
Hypertension*

NoYes
If yes, please indicate whether self and/or family and give details/list relation.
Elevated Cholesterol*

NoYes
If yes, please indicate whether self and/or family and give details/list relation.
Diabetes (List type, duration)*

NoYes
If yes, please indicate whether self and/or family and give details/list relation.
Thyroid Disfunction (high or low)*

NoYes
If yes, please indicate whether self and/or family and give details/list relation.
Gastrointestinal Dysfunction*

NoYes
If yes, please indicate whether self and/or family and give details/list relation.
Skin Disorder*

NoYes
If yes, please indicate whether self and/or family and give details/list relation.
Nervous System Disorder*

NoYes
If yes, please indicate whether self and/or family and give details/list relation.
Cardiovascular Disorder*

NoYes
If yes, please indicate whether self and/or family and give details/list relation.
Muscoskeletal Disorder (i.e. arthritis)*

NoYes
If yes, please indicate whether self and/or family and give details/list relation.
List any other medical conditions
Medications and Dosages
Allergies
Social History
Do you smoke?

YesNoPrior
Do you consume alcohol?

YesNo
If yes, number of drinks/week?
Do you use illicit drugs?

YesNo
If yes or prior, type?
Vision insurance
Vision Insurance

NoYes
If yes, please list.
Primary Insured's Name*

First NameLast Name
Primary's Member ID #
Group #
Relationship of Patient to Primary*

SelfSpouseChild
Primary's Social Security #*
Primary's Birth Date*

DayMonthYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary's Home Phone*

Area CodePhone Number
Primary's Cell Phone*

Area CodePhone Number
Primary's Gender*

MaleFemale
Primary's Employer*
Work Phone*

Area CodePhone Number
Medical insurance
Medical Insurance*

NoYes
If yes, please list.
Primary's Member ID #
Group #
Primary Insured's Name*

First NameLast Name
Relationship of Patient to Primary*

SelfSpouseChild
Primary's Social Security #*
Primary's Birth Date*

DayMonthYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary's Home Phone*

Area CodePhone Number
Primary's Cell Phone*

Area CodePhone Number
Primary's Gender*

MaleFemale
Primary's Employer*
Specialist Co-Payment
Should be Empty:

Southlands Vision Associates

Party Responsible for Account

Primary Reason for Visit Today

Medical History

Social History

Vision insurance

Medical insurance