Patient Information Form

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please enter a valid phone number.

Do you work at a Desktop? Laptop? Tablet? Phone? YES or NO How many hours per day?

Do you spend time outdoors? YES or NO How many hours per week?

Do you play any sports?

Do you consume alcohol? YES or NO How often?

Do you use any tobacco products? YES or NO How often?

HIPAA ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES: I hereby acknowledge I understand Linsey Eyecare's Notice of Privacy Practices. Furthermore, I acknowledge that a copy of the current notice is posted in the reception area. If you would like to receive a printed copy, please request it at the reception desk during check-in.

Please be advised if you are using insurance coverage for today's visit, this is a contract between you and your insurance company, not Linsey Eyecare. If your insurance company does not reimburse our office, you are responsible for providing payment to Linsey Eyecare upon receipt of invoice.

PERSONAL EYE HEALTH

No correctionEyeglassesContact lenses

AcceptableMay need improvementBlurred

No correctionEyeglassesContact lensesContact lenses with glasses

AcceptableMay need improvementBlurred

No correctionEyeglassesContact lensesContact lenses with glasses

AcceptableMay need improvementBlurred

PERSONAL HEALTH HISTORY

Have you ever been told you have any of the following conditions? If YES, please check the appropriate conditions.

High CholesterolAnemia

HypertenstionHeart failureHeart disease

Ear conditionsNose conditionsThroat conditionsSinus issues

EpilepsyMultiple SclerosisMigraineAutism

DepressionAnxiety DisorderBipolar Disorder

AsthmaCOPDEmphysemaSleep Apnea

Crohn's diseaseColitisCeliac diseaseReflux

Kidney disease/stonesProstate disease

RosaceaPsoriasisHerpes SimplexHerpes Zoster/shingles

LupusSjogren's SyndromeRheumatoid Arthritis

ADDHADyslexiaOther learning difficulties

Are you currently taking any medications? Please list.

Are you currently using any eye drops? Either over-the-counter or prescribed? YES or NO If yes, what?

Do you have any drug allergies? YES or NO If yes, what?

Do you have any environmental allergies? YES or NO If yes, what?

Are you allergic to latex? YES or NO

FAMILY HISTORY

Has anyone in your family ever been diagnosed with the following conditions? If yes, who?

Diabetes mellitus type 1

Diabetes mellitus type 2

Early onset cataracts

Age-related macular degeneration