Southlands Vision Patient Form

Southlands Vision Associates

Fill out your medical information carefully
Patient Information

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

Male Female
Marital Status

Married Single Widow
Birth Date

Month Day Year
Age
Home Phone

Area Code Phone Number
Day Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
E-mail
Preferred Method of Contact

Home Phone Day Phone Cell Phone Text (Must provide cell number above) Email

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

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

Prior Patient Drive-by Insurance Internet Friend/Family LensCrafters Advertising
Party Responsible for Account
Name

First Name Last Name
Home phone

Area Code Phone Number
Cell phone

Area Code Phone Number
Relationship to patient

Self Spouse Parent/Guardian

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Birth Date

Month Day Year
Primary Reason for Visit Today
Check any

Blurred Distance Vision Blurred Near Vision Blurred Intermediate Vision Eye Irritation/discomfort Eye Infection/Discharge Seeing flashes of light Having headaches related to vision Seeing floaters/changes to floaters
List any other reason for your visit
Do you wear glasses

No Yes Prior
If worn, for what purpose?

Far Near Computer All distances Full time Part time
Do you wear contacts

No Yes Prior
If worn, brand/powers?
Do you sleep in them?

Yes No
If you do not wear contact lenses, are you interested?

Yes No Maybe (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 *

No Yes
If yes, please indicate whether self and/or family and give details/list relation.
Strabismus/Turned Eye *

No Yes
If yes, please indicate whether self and/or family and give details/list relation.
Dry Eye Syndrome/Symptoms *

No Yes
If yes, please indicate whether self and/or family and give details/list relation.
Eye Surgery or Therapy (Type) *

No Yes
If yes, please indicate whether self and/or family and give details/list relation.
Eye Injury (type, timeline, status) *

No Yes
If yes, please indicate whether self and/or family and give details/list relation.
Macular Degeneration *

No Yes
If yes, please indicate whether self and/or family and give details/list relation.
Glaucoma *

No Yes
If yes, please indicate whether self and/or family and give details/list relation.
Retinal Detachment/ Hole/ Repair *

No Yes
If yes, please indicate whether self and/or family and give details/list relation.
Hypertension *

No Yes
If yes, please indicate whether self and/or family and give details/list relation.
Elevated Cholesterol *

No Yes
If yes, please indicate whether self and/or family and give details/list relation.
Diabetes (List type, duration) *

No Yes
If yes, please indicate whether self and/or family and give details/list relation.
Thyroid Disfunction (high or low) *

No Yes
If yes, please indicate whether self and/or family and give details/list relation.
Gastrointestinal Dysfunction *

No Yes
If yes, please indicate whether self and/or family and give details/list relation.
Skin Disorder *

No Yes
If yes, please indicate whether self and/or family and give details/list relation.
Nervous System Disorder *

No Yes
If yes, please indicate whether self and/or family and give details/list relation.
Cardiovascular Disorder *

No Yes
If yes, please indicate whether self and/or family and give details/list relation.
Muscoskeletal Disorder (i.e. arthritis) *

No Yes
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?

Yes No Prior
Do you consume alcohol?

Yes No
If yes, number of drinks/week?
Do you use illicit drugs?

Yes No
If yes or prior, type?
Vision insurance
Vision Insurance

No Yes
If yes, please list.
Primary Insured's Name *

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

Self Spouse Child
Primary's Social Security # *
Primary's Birth Date *

Day Month Year

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Primary's Home Phone *

Area Code Phone Number
Primary's Cell Phone *

Area Code Phone Number
Primary's Gender *

Male Female
Primary's Employer *
Work Phone *

Area Code Phone Number
Medical insurance
Medical Insurance *

No Yes
If yes, please list.
Primary's Member ID #
Group #
Primary Insured's Name *

First Name Last Name
Relationship of Patient to Primary *

Self Spouse Child
Primary's Social Security # *
Primary's Birth Date *

Day Month Year

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Primary's Home Phone *

Area Code Phone Number
Primary's Cell Phone *

Area Code Phone Number
Primary's Gender *

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