Welcome to Our Office
Welcome to Our Office
Thank you for taking the time to provide this important information.
Today’s Date________________________
Name____________________________________ Spouse or Parents__________________________________
Address_________________________________ City__________________ State______ Zip______________
Home Phone(____)______________ Work Phone(____)_______________ Cell(____)____________________
E-Mail ________________________ Date of Birth__________________________ Age _________
Do you prefer to receive calls at: ( Home ( Work ( Cell ( Email ( No Preference
Patient Employer ___________________________ Occupation______________________________________
Patient School (if child)________________________ Grade(if child)_________________________________
Person to contact in case of emergency_________________________ Phone(____)______________________
How did you first hear about our office?
Phone Book ( Fiest ( SBC ( News Paper ( Insurance ( Website ( Community Event _________
Friend or Relative Who? ________________ Physician Who? _______________ Other __________________
What is your major purpose of this visit?______________________________________________________
Any concerns with you present contacts or glasses?______________________________________________
When was your last eye exam _________________________ Eye Doctors Name________________________
Do you currently wear glasses? ( Yes ( No Do you wear them? ( Full time ( Distance only ( Near only
Do you currently wear contacts? ( Yes ( No Type_________________________________________________
Are you interested in contacts? ( Yes ( No
Are you interested in corrective eye surgery (LASIK)? ( Yes ( No
Are you currently or have you recently experienced any of the following?
( Sensitivity to light ( Floaters or spots ( Double vision ( Trouble seeing at night
( Eye Strain ( Blurry distance vision ( Blurry near vision ( Sensitivity to glare
( Itching ( Watering ( Burning
( Other ___________________________________________________________________________________
Please list any medications you are currently taking Rx or over the counter
(if you have a list we would be happy to make a copy)
____________________________________________________________________________________________________________________________________________________________________________________
Vitamins, Mineral and Herbs __________________________________________________________________
__________________________________________________________________________________________
Allergies to Medications______________________________________________________________________
Personal Medical History
( Pregnant ( Nursing ( Cancer ( Macular Degeneration
( Heart Disease ( Diabetes ( Fibromyalgia ( Thyroid Disease
( Glaucoma ( High Blood Pressure ( Arthritis ( Eye Surgery
( Eye Injury ( High Cholesterol ( Allergies ( Other_______________
Name of Physician _______________________________ Date of last physical exam_____________________
Family Medical History
( High Cholesterol ( High Blood Pressure ( Cancer ( Macular Degeneration
( Heart Disease ( Diabetes ( Glaucoma
( Other ___________________________________________________________________________________
Dr. Lewis J. LaPierre, Jr Dr. Travis K. Sharpe
2069 S. Ohio Salina, Ks 67401 (785)827-9898
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