somerseyecenter.com - Patient Information

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ARTHRITIS:

ASTHMA:

CANCER:

ALLERGIES:

BLINDNESS:

DIABETES:

GLAUCOMA:

HEART DISEASE:

HIGH BLOOD PRESSURE:

MACULAR DEGENERATION:

STROKE:

OTHER MEDICAL CONDITIONS IN FAMILY MEMBERS NOT LISTED ABOVE:

MARITAL STATUS:

SINGLEMARRIEDDIVORCEDWIDOWED

TOBACCO USE:

NEVERFORMER - Great job quitting!YES

DAILY AMOUNT:

DATE QUIT:

Date

TYPE: (cigarettes, pipe, vape, chewing tobacco, etc.)

Please note that Drs. Blacklock and Loughman strongly recommend not smoking, as it causes damage throughout your body, including to your eyes!

ALCOHOL INTAKE:

OCCUPATION:

if working, my occupation is

Do you feel you are at risk to fall, or have you fallen in the last year?

YesNo

REASON FOR YOUR VISIT TODAY:

DURATION OF SYMPTOMS/PROBLEMS:

Please list anything that you are currently using in your eyes (drops, ointments, saline, etc.):

GLASSES:

CURRENTPASTNEVER

CONTACT LENSES:

CURRENTPASTNEVER

CATARACTS:

CATARACT SURGERY:

RETINAL DISEASE:

RIGHTLEFTBOTHNo

REFRACTIVE SURGERY:

RIGHTLEFTBOTHNo

RETINAL SURGERY:

RIGHTLEFTBOTHNo

LASER SURGERY:

RIGHTLEFTBOTHNo

CORNEAL TRANSPLANT:

RIGHTLEFTBOTHNo

RETINAL DETACHMENT:

RIGHTLEFTBOTHNo

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HELPING US PROVIDE YOU WITH THE BEST CARE POSSIBLE!

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DATE

Date

Patient Information

ALTERNATIVE CONTACT PERSON:

PRIMARY INSURANCE CARRIER:

RESPONSIBLE PARTY NAME (if not yourself):

PATIENT HEALTH HISTORY

FAMILY MEDICAL HISTORY:

SOCIAL HISTORY:

FALL RISK:

EYE HISTORY: