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Patient Information Form

 

Please fill out the form below and submit it prior to your appointment and we will have your paperwork ready and completed for you when you arrive. If you have not scheduled your appointment yet, you may use our online appointment request form or give us a call. Required fields are marked with asterisks (*).

 

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Personal Information

Clinic Location: *

ABQ-North Valley - 6601 4th Street
ABQ-Northeast Heights - 9204 Menaul Blvd.
ABQ-Westside - 1646 Alameda Blvd.
Los Alamos - 800 Trinity Drive

Name (Last, First, MI): *

Home Phone: *

Work Phone: *

Cell Phone:

Email Address: *

Preferred Method of Contact:

Texting OK?

Yes No

Street Address: *

City: *

State: *

Zip: *

Birth Date: *

Social Security Number:

Sex: *

  Male    Female  

Marital Status:

Single
Married
Divorced
Widowed

Preferred Language: *

English  Spanish  

Race: *

Ethnicity: *

Parent or Legal Guardian:

Employer:

Occupation:

Employment Status:

Full time  Part time  Self-employed  

Date / Location of last eye examination:

 

How did you hear about our office?

I am a previous patient

Friend or relative:  

Another doctor:  

Yellow pages, which book:  

Insurance plan directory:  

Other:  

 

Medical History

Do you or a family member currently have any of the following health problems or conditions?

Allergies

family

self

 

Heart Disease

family

self

 

Excessive Thirst or Urination

family

self

 

Excessive Bleeding

family

self

 

High blood pressure

family

self

 

Diabetes

family

self

 

Thyroid Condition

family

self

 

Gastrointestinal Disease

family

self

 

Genitourinary Disease

family

self

 

Dental or Sinus Condition

family

self

 

Blood Disease

family

self

 

Immune Disease

family

self

 

Skin Disease

family

self

 

Muscle or Bone Disease

family

self

 

Neurological Disease

family

self

 

Psychological Condition

family

self

 

Breathing Disorder

family

self

 

Other

 

 

 

Ocular History

Do you or a family member currently have any of the following eye problems or conditions?

Cataracts

family

self

 

Corneal Ulcer

family

self

 

Glaucoma

family

self

 

Retinal Disease (Macular Degeneration)

family

self

 

Strabismus (Lazy Eye)

family

self

 

Other

 

 

 

Medications

Please list any eye medications you are currently taking.

Please list any known allergies to medications.

Please list any medications or dietary supplements you are currently taking.

Please list any eye surgeries you have had.

 

Social and Developmental History

Please answer the following questions.

Height:

Weight:

Are you currently pregnant?

Yes No

Do you smoke or use tobacco products?

Yes No

        How often?

Do you drink alcohol?

Yes No

        How often?

Do you use any illegal drugs?

Yes No

        How often?

Have you had any sexually transmitted diseases?

Yes No

Have you ever had a blood transfusion?

Yes No

Do you have a history of any developmental problems or conditions?

Yes No

Explain:

 

Glasses and Contact Lens History

Please answer the following questions about your glasses and/or contact lenses.

What kind of glasses do you wear?

general purpose

 

 

reading

 

 

bifocal

 

 

progressive

 

 

Other:

When do you wear your glasses?

full-time
hardly ever
occasionally to see far away
only to read

Describe any problems you are having with your glasses:

Do you currently wear contact lenses?

yes
no
wore them in the past

What kind of contacts do you wear?

disposable

 

 

toric

 

 

rigid gas-permeable

 

 

bifocal

 

 

monovision

 

How often do you replace your contacts?

daily
2-weeks
monthly
quarterly
yearly

Other:

Describe any problems you are having with your contact lenses:

 

Computer Use History

Please answer the following questions.

How many hours do you spend working on the computer each day?

 

How many inches from your eyes is the center of the computer screen?

 

Is the top of your computer screen at, above, or below eye level?

 

Do you experience any of the following visual symptoms while working on the computer?

eye strain

 

 

headaches

 

 

fatigue

 

 

slow focus recovery

 

 

squinting

 

 

glare

 

 

Eye Comfort History

Please answer the following questions.

Do you experience any of the following ocular symptoms during the day?

eye fatigue

 

 

eye pain

 

 

dryness

 

 

redness

 

 

burning

 

 

itching

 

 

swollen eyelids

 

 

watery discharge

 

 

Activities

Please indicate if you participate in any of the following activities or sports.

Baseball/Softball

Yes No

Tennis

Yes No

Swimming

Yes No

Soccer

Yes No

Scrapbooking

Yes No

Running/Jogging

Yes No

Knitting

Yes No

Jewelry Making

Yes No

Hunting

Yes No

Golfing

Yes No

Fishing

Yes No

Cycling

Yes No

Beadwork

Yes No

Other

 

Insurance

Who is your medical insurance carrier?

Name of primary insured:

Birth date and SS# of primary insured:

What is the name of your vision plan?

Name of primary insured for your vision plan:

Birth date and SS# of primary insured for your vision plan:

 

Check this box to indicate you have completed this form before hitting the SUBMIT button. *

 

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1646 Alameda NW, Albuquerque, NM  |  800 Trinity Drive, Suite J-2, Los Alamos, NM