burbankvision.com-ADULT QUESTIONNAIRE FOR NEW AND RETURNING PATIENTS

Burbank Optometric Center, Inc.
Adult Medical History - New and Established Patients

New patients: Please fill out form completely.
Established patients: Please provide any changes to your information
and any new symptoms/problems/concerns.

Salutation:

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone

Area CodePhone Number

Cell Phone

Area CodePhone Number

Email

example@example.com

Date of Birth

Social Security #

Emergency Contact

Name

First NameLast Name

Relationship

Phone Number

Area CodePhone Number

Signature

How were you referred to our office?

If Patient, First and last name:

First NameLast Name

INSURANCE: Please bring all insurance cards with you.

Primary Vision Insurance

Company Name

Identification Number

Group Number

Insured’s Name

Insured's Date of Birth

Patient's Relation to Insured

Secondary Vision Insurance

Company Name

Identification Number

Group Number

Insured’s Name

Insured's Date of Birth

Patient's Relation to Insured

Primary Medical Insurance

Company Name

Identification Number

Group Number

Insured’s Name

Insured's Date of Birth

Patient's Relation to Insured

Secondary Medical Insurance

Company Name

Identification Number

Group Number

Insured’s Name

Insured's Date of Birth

Patient's Relation to Insured

SYMPTOMS: Check all that apply.

EYEGLASSES (Skip if you do not wear glasses)

CONTACT LENSES (Skip if you don't wear contacts)

Rows	Answer
What brand/name of contacts do you wear?
How old are your current pair of contacts?
How often do you dispose of your lenses?
What brand of solution do you soak your lenses in?
How many days per week do you wear your contacts?
How many hours per day?
How many hours do you experience clear vision and good comfort?

Do you use eye drops?

If yes, name and frequency of use

I am having problems with my current contacts:

ELECTRONIC USE

Average # of hrs/day of electronics, including phone, tablet, computer, TV, gaming:

# of monitors used:

Working distance from monitor (measure from your eyes to the center of monitor):

I am having symptoms of electronic overload:

I am having symptoms of dry eye/allergy eyes:

I am having trouble seeing at night:

I am experiencing:

Please list any eye injuries, surgeries or infections you have ever had and when:

Rows	Select (If apply)	Explain
Glaucoma, who and age diagnosed
Retinal hole/tear/detachment, who and age diagnosed?
Cataracts, who and age diagnosed
Amblyopia (lazy eye), who?
Strabismus (eye turn), who?
Macular degeneration, who and age diagnosed
Other (please explain)

Rows	Select (If apply)	Explain	Who
High blood pressure, who?
Diabetes, who?
High cholesterol, who?
Cancer, type?
Auto-immune disorders, type?
Neurological (Alzheimer’s, dementia, Parkinson’s, etc.), type?

Patient Information

MEDICAL HISTORY

Social History