Blink Vision Center // Dr. Lindsay Alexander // Terrell, Texas



Patient Health QuestionnairePatient: __________________________________ Occupation: ___________________________________________DOB: __________________________ Age:________ Gender: M / F Phone:_____________________________Home Address: ______________________________________ City:______________________ State:____________ ZIP Code:____________May we text you at this number for appointment reminders and for glasses/contact lens pickup? Yes NoVision Insurance: _________________________ ID:___________________________ Primary SSN: _______-_______-________Medical Insurance: _______________________ ID:___________________________ Primary Care Physician: _____________________________ Primary Care Physician Phone Number: ____________________________Please circle any CURRENT eye concerns:Itchy Eyes Pain Red Eye Dry Eye CataractsRetinal Detachment Blurry VisionBurning Eyes Eye Fatigue Eye Strain Squinting Eye TurnMacular DegenerationHeadache Double Vision Floaters Watering GlaucomaFlashes of lightDo you currently wear glasses? Yes No Have you noticed a change in vision with your glasses/contacts? Yes NoDo you have glare or trouble driving at night? Yes No Do you work at a computer? Yes No How many hours/day? ______Do you currently wear contact lenses? Yes No Are you interested in learning more about contact lenses today? Yes NoDo you play sports? Yes No Do you have a need for sports goggles? Yes No Are you a smoker? Yes No Alcohol use? Yes No Narcotic use: Yes No Female Patients: Pregnant? Yes No Breastfeeding? Yes No-5080115571Please circle any CURRENT or PAST problems:MigrainesWeight gain/lossTrouble breathingAllergiesAsthmaCOPDEmphysemaDiabetesHeart DiseaseHigh Blood PressureHigh CholesterolStomachArthritisMuscle PainJoint PainAnemiaBleeding ThyroidAnxietyRosaceaDepressionRashBipolarSjogren’sEczemaHIV/AIDS00Please circle any CURRENT or PAST problems:MigrainesWeight gain/lossTrouble breathingAllergiesAsthmaCOPDEmphysemaDiabetesHeart DiseaseHigh Blood PressureHigh CholesterolStomachArthritisMuscle PainJoint PainAnemiaBleeding ThyroidAnxietyRosaceaDepressionRashBipolarSjogren’sEczemaHIV/AIDS4338320115570Please circle if anyone in your FAMILY has any of these conditions and indicate their relationship to you:Diabetes___________________Heart Disease___________________High Cholesterol___________________High Blood Pressure___________________Thyroid Disease___________________Blindness___________________Glaucoma___________________Cancer___________________Macular Degeneration___________________Retinal Detachment___________________Other___________________00Please circle if anyone in your FAMILY has any of these conditions and indicate their relationship to you:Diabetes___________________Heart Disease___________________High Cholesterol___________________High Blood Pressure___________________Thyroid Disease___________________Blindness___________________Glaucoma___________________Cancer___________________Macular Degeneration___________________Retinal Detachment___________________Other___________________2204720115570Current Medications (Please list):________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Allergies (medication/other):___________________________________________________________________________________________________00Current Medications (Please list):________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Allergies (medication/other):___________________________________________________________________________________________________Please list any major general surgeries or hospitalizations (please include approximate dates): _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________-717551021079ROS:_________ Date: _________ROS:_________ Date: _________ROS:_________ Date: _________0ROS:_________ Date: _________ROS:_________ Date: _________ROS:_________ Date: _________Sign:________________________________ Print:_________________________________ Date: _______________ ................
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