Primary Eyecare Associates - lasik, lasik surgery, cataract treatment, cataract surgery, glaucoma treatment, blepharoplasty


First Name*	Last Name*
Street	Apartment
City	State	Post Code
Phone Number	E-mail Address*
Date of Birth	Sex
Purpose of this visit?
Any problems with your present contact lenses or glasses?
Spouse (or Parent's) Name?
Spouse (or Parent's) Work Phone?
Vision Insurance?

MEDICAL HISTORY
Allergies	Asthma
Skin Disorders	Eye Diseases
Eye Injury	Eye Surgery
Lazy Eye	Cataracts
Glaucoma	Macular Degeneration
Arthritis	Cancer
Diabetes	Heart Disease
High Blood Pressure	Nerves
Pregnant

DO YOU...
Work at a computer for long periods?
Have more than one pair of glasses?
Want information on thinner, lighter glasses?
Have problems with glare or reflection, when driving at night?
Have prescription sunglasses?
Do you wear bifocals?
Have family members in need of eyecare?
Have you ever worn / are you currently wearing contacts?
Are you interested in contact lenses?
Have you ever considered color contacts?

DO YOU EXPERIENCE...
Burning	Itchiness
Tearing	Dryness
Eye Strain	Glare or Reflection
Uncomfortable contacts	Trouble working up close
Spots	Soreness
Flashes of light	Headaches
Redness	Double Vision
Uncomfortable glasses	Sudden loss of vision
Sensitivity to light	Fainting or Dizziness
Blurry distance vision	Gritty feeling of eyes
Trouble seeing at night	Trouble reading or learning

CURRENT MEDICATIONS (Rx or Over the Counter) Leave BLANK if none
Antihistamines?
High Blood Pressure?
Oral Contraceptives?
Blood Sugar?
Eye Drops?
Other?
Are you allergic to any medicine?
Name of your physician?

FAMILY MEDICAL HISTORY Print The Family Members Relationship, Leave BLANK if none
Macular Degeneration?
Cataracts?
Glaucoma?
Diabetes?
Heart Disease?
Other?