1st Eye Care

Patient Information Form

Personal Information

First Name	Last Name	Middle Initial	Date of Birth	Age

Street Address / PO Box	City	State	ZIP

Sex	Marital Status	E-Mail Address	Home Phone	Cell Phone
M F

First Visit?	Reason for Current Visit	Last Eye Exam Date	Referred By
Yes No

Employment Status	Employer	Emp. Phone	Occupation

Employer Street	Employer City	Emp. State	Emp. ZIP

Other Contact Information

Person Responsible for charges (if not patient)	Relationship to Patient	Home Phone	Work Phone

Emergency Contact	Relationship to Patient	Home Phone	Work Phone

Eye Health - Patient

(Check all that Apply) Amblyopia (Lazy Eye)Eye SurgeriesInfection of Eye / Lid
Blurred Vision - FarEye TurnItchy Feeling
Blurred Vision - NearFloaters / SpotsLoss of Vision - Central
Burning EyesFluctuating VisionLoss of Vision - Side
CataractsForeign Body SensationMucus / Discharge
Double / Distorted VisionGlare / Light SensitivityRedness
Drooping EyelidGlaucomaRetinal Detachment
Dry EyesHeadachesTearing / Watery Eyes

General Health - Patient

(Check all that Apply) Allergies / Hay feverChronic CoughKidney Disease
Asthma / RespiratoryDiabetesPsychiatric / Depression
Blood DisordersEmphysemaRheumatoid Arthritis
CancerGastrointestinal ProblemsSkin Disorders
Cardiovascular / High B.P.Headaches / MigrainesThyroid / Endocrine Disease
Chronic BronchitisHeart Attack / StrokeWeight Loss / Gain

Family History - Blood Relatives

(Check all that Apply) Amblyopia (Lazy Eye)Color BlindnessHigh Cholesterol
ArthritisDiabetesMacular Degeneration
BlindnessEye TurnRetinal Detachment
CancerGlaucomaStroke / Heart Attack
Cataract(s)High Blood PressureThyroid Disease

Family Physician

Physician's Name	Physician's Phone	Last Medical Exam Date

Enter all medications taken by patient and for what condition each is taken.

	Medication	Condition	If Other
1
2
3
4
5
6
7
8

Enter the name of all medications (or substances) to which the patient is allergic:

Please Answer The Following Questions:

Are you pregnant or nursing?

Yes

Do you have trouble driving at night?

Yes

Do you wear glasses?

Yes

Contacts?

Yes

If Contacts, Type:

Do you experience blur, headaches or eyestrain with computer use?

Yes

Are you interested in laser (refractive) surgery to correct your vision?

Yes

I Have Questions

Vision Insurance

Insurance Company

Insured's Sex

Patient's Relationship to Insured:

Insured's ID #		Group #		Insured's Date of Birth
Insured's Name		Insured's Phone

Primary Health Insurance

Insurance Company

Insured's Sex

Patient's Relationship to Insured:

Insured's ID #		Group #		Insured's Date of Birth
Insured's Name		Insured's Phone

Medicare Secondary Health Insurance

Insurance Company

Insured's Sex

Patient's Relationship to Insured:

Insured's ID #		Group #		Insured's Date of Birth
Insured's Name		Insured's Phone

Please enter any comments or additional Information we should know.

Drs. Kret, Bond, Bond & Miller

Tim Kret, O.D., P.A.
Michael Bond, O.D.
Lindsay Bond, O.D.
Matt Miller, O.D.
Kendra DeBerry O.D.