burbankvision.com-ADULT QUESTIONNAIRE FOR NEW AND RETURNING PATIENTS

Burbank Optometric Center, Inc.
Adult Medical History - New and Established Patients

New patients: Please fill out form completely.
Established patients: Please provide any changes to your information
and any new symptoms/problems/concerns.
Patient Information
Salutation:

Dr.Mr.Mrs.Ms.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Email
example@example.com
Date of Birth

MonthDayYear
Social Security #
Emergency Contact
Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
I give permission for my personal health information to be released to the person named above.
Signature

Clear
How were you referred to our office?

GoogleFBYelpInternetInsurancePatient
If Patient, First and last name:

First NameLast Name
INSURANCE: Please bring all insurance cards with you.

Primary Vision Insurance
Company Name
Identification Number
Group Number
Insured’s Name
Insured's Date of Birth
Patient's Relation to Insured
Secondary Vision Insurance
Company Name
Identification Number
Group Number
Insured’s Name
Insured's Date of Birth
Patient's Relation to Insured
Primary Medical Insurance
Company Name
Identification Number
Group Number
Insured’s Name
Insured's Date of Birth
Patient's Relation to Insured
Secondary Medical Insurance
Company Name
Identification Number
Group Number
Insured’s Name
Insured's Date of Birth
Patient's Relation to Insured
SYMPTOMS: Check all that apply.

EYEGLASSES (Skip if you do not wear glasses)
I currently wear:
Non-prescription sunNon-prescription blue light/UVSingle vision distanceSingle vision readingSingle vision computerSingle vision sunglassesSingle vision safetySingle vision sportsBifocal (lined) for distance/readingBifocal for computer/readingTrifocal (lined)Progressive (no line) for everythingProgressive for computer/readingProgressive sunglassProgressive safetyProgressive sports
I am having problems with my current glasses:
Distance blurComputer blurNear blurFrame brokeFrame looseFrame is uncomfortableLostI want a new style
I need new glasses
Everyday useSpare SunSafetySportsBlue light/UV
CONTACT LENSES (Skip if you don't wear contacts)

	Answer
What brand/name of contacts do you wear?
How old are your current pair of contacts?
How often do you dispose of your lenses?
What brand of solution do you soak your lenses in?
How many days per week do you wear your contacts?
How many hours per day?
How many hours do you experience clear vision and good comfort?

Do you use eye drops?

YesNo
If yes, name and frequency of use
I am interested in changing/enhancing my eye color.I am interested in Transitions contact lenses.I am interested in contact lenses but do not currently wear them.I am having problems with my current contacts.
I am having problems with my current contacts:

Distance blurComputer blurNear blurDiscomfortDrynessOld
ELECTRONIC USE
Average # of hrs/day of electronics, including phone, tablet, computer, TV, gaming:
# of monitors used:
Working distance from monitor (measure from your eyes to the center of monitor):
I am having symptoms of electronic overload:I am having symptoms of dry eye/allergy eyes:I am having trouble seeing at night:I am experiencing:I am interested in LASIK.
I am having symptoms of electronic overload:

EyestrainTired eyesHeadachesBlurred visionDouble visionFluctuating visionEye painLight sensitivity
I am having symptoms of dry eye/allergy eyes:

Sandy/gritty feelBurningTearingRednessItchingDrynessBlurred visionMucousCrusting around eyelashes
I am having trouble seeing at night:

GlareCan’t seeHalos around lights
I am experiencing:

FloatersFlashes of lightcShadowsLoss of vision
Please list any eye injuries, surgeries or infections you have ever had and when:

	Select (If apply)	Explain
Glaucoma, who and age diagnosed
Retinal hole/tear/detachment, who and age diagnosed?
Cataracts, who and age diagnosed
Amblyopia (lazy eye), who?
Strabismus (eye turn), who?
Macular degeneration, who and age diagnosed
Other (please explain)

	Select (If apply)	Explain	Who
High blood pressure, who?
Diabetes, who?
High cholesterol, who?
Cancer, type?
Auto-immune disorders, type?
Neurological (Alzheimer’s, dementia, Parkinson’s, etc.), type?

Patient Information

MEDICAL HISTORY

Social History