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

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download