Southlands Vision Patient Form

Southlands Vision Associates

Fill out your medical information carefully
Patient Information

First NameLast Name
First Name
Middle Name
Last Name
SS#
Gender
Marital Status
Birth Date

MonthDayYear
Age
Home Phone

Area CodePhone Number
Day Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
E-mail
Preferred Method of Contact
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Occupation
Employer
Hobbies/Special Needs
How did you hear about our office?
Party Responsible for Account
Name

First NameLast Name
Home phone

Area CodePhone Number
Cell phone

Area CodePhone Number
Relationship to patient
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date

MonthDayYear
Primary Reason for Visit Today
Check any
List any other reason for your visit
Do you wear glasses
If worn, for what purpose?
Do you wear contacts
If worn, brand/powers?
Do you sleep in them?
If you do not wear contact lenses, are you interested?
Date of last exam and doctor
Date of last physical
Medical History

For each line please indication Self and/or Family and give details/list relation
Amblyopia/Lazy Eye
If yes, please indicate whether self and/or family and give details/list relation.
Strabismus/Turned Eye
If yes, please indicate whether self and/or family and give details/list relation.
Dry Eye Syndrome/Symptoms
If yes, please indicate whether self and/or family and give details/list relation.
Eye Surgery or Therapy (Type)
If yes, please indicate whether self and/or family and give details/list relation.
Eye Injury (type, timeline, status)
If yes, please indicate whether self and/or family and give details/list relation.
Macular Degeneration
If yes, please indicate whether self and/or family and give details/list relation.
Glaucoma
If yes, please indicate whether self and/or family and give details/list relation.
Retinal Detachment/ Hole/ Repair
If yes, please indicate whether self and/or family and give details/list relation.
Hypertension
If yes, please indicate whether self and/or family and give details/list relation.
Elevated Cholesterol
If yes, please indicate whether self and/or family and give details/list relation.
Diabetes (List type, duration)
If yes, please indicate whether self and/or family and give details/list relation.
Thyroid Disfunction (high or low)
If yes, please indicate whether self and/or family and give details/list relation.
Gastrointestinal Dysfunction
If yes, please indicate whether self and/or family and give details/list relation.
Skin Disorder
If yes, please indicate whether self and/or family and give details/list relation.
Nervous System Disorder
If yes, please indicate whether self and/or family and give details/list relation.
Cardiovascular Disorder
If yes, please indicate whether self and/or family and give details/list relation.
Muscoskeletal Disorder (i.e. arthritis)
If yes, please indicate whether self and/or family and give details/list relation.
List any other medical conditions
Medications and Dosages
Allergies
Social History
Do you smoke?
Do you consume alcohol?
If yes, number of drinks/week?
Do you use illicit drugs?
If yes or prior, type?
Vision insurance
Vision Insurance
If yes, please list.
Primary Insured's Name

First NameLast Name
Primary's Member ID #
Group #
Relationship of Patient to Primary
Primary's Social Security #
Primary's Birth Date

DayMonthYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary's Home Phone

Area CodePhone Number
Primary's Cell Phone

Area CodePhone Number
Primary's Gender
Primary's Employer
Work Phone

Area CodePhone Number
Medical insurance
Medical Insurance
If yes, please list.
Primary's Member ID #
Group #
Primary Insured's Name

First NameLast Name
Relationship of Patient to Primary
Primary's Social Security #
Primary's Birth Date

DayMonthYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary's Home Phone

Area CodePhone Number
Primary's Cell Phone

Area CodePhone Number
Primary's Gender
Primary's Employer
Specialist Co-Payment
Should be Empty: