Last:			Date:
First:
MI:
Title: Mr Mrs Ms Dr Other
Date of Birth:			Race:
Age:			Cauc. African Am. Hisp.
Sex:	Male Female		Asian Other

Social Security #:
Street:
City:
State:
Zip:
Home Phone:
Employer:
Work Phone:
Work:	full-time part-time
Referred by?
Insurance:
Vision:
Medical:
Policy Holder:
Occupation:
Hobbies/Sports:
Use a computer?	No Yes

Are you interested in:

Are you having any problems with your eyes?
No Yes (if yes--check or explain below)

Blur at Far Blur at computer Blur at near Pain Itch Burn Tearing

Explain:

Last eye exam:	(yr)
Last eye Dr.
Your medical Dr.
Dr. phone number:

Do you currently wear--eyeglasses? Yes No
Do you currently wear--contact lenses? Yes No
If you have ever worn contact lenses--please (briefly)
describe lens types and any problems:

Have you ever been diagnosed or treated for (No or Yes)

Glaucoma (high eye pressure)	Yes No
Cataracts	Yes No
Lazy eye	Yes No
Blindness or other eye problems (if yes, explain below)	Yes No
List any eye drops that you use regularly:

Explain:

Do you have any of the following health problems? (CHECK)
diabetes high blood pressure heart kidney thyroid
allergies sinus cancer arthritis

Other (describe)


Medication Allergies?

Seasonal Allergies?

List ALL current medicines (for eyes or general health):

Do you smoke?	Yes No
Were you ever a smoker?	Yes No	# of years smoked:
Alcohol abuse?	Yes No
Drug abuse?	Yes No

Do any of your blood relatives have glaucoma or any other serious eye problems?
Yes No
(If yes, explain)

If you wear contact lenses please continue below:

Present lenses are:	soft gas permeable hard far vision astigmatic monovision bifocal N/A
Lenses are worn:	daily wear occassional overnight regularly overnight Label N/A
Lenses are replaced:	daily weekly monthly bimonthly yearly N/A
How old are your current lenses:
How long have your lenses been in prior to this visit:
When were you fit with present lenses (yr):
Name of fitting Doctor:
List your clean/disinfect/lubrication solutions:
Are you having any problems with your present contact lenses?	Yes No
Purpose of your visit today:	N/A Replace current lens type New lens type Discontinue
Note: Contact lenses sometimes cause corneal distortions -- additional visits and temporary discontinuation of lens wear may be required. Additional visits are not covered by insurance. Your CL Rx is available AFTER all fitting/followup is complete.