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Welcome Form

Welcome to St. Croix Vision Center and Optical.  Thank you for choosing us for your eye care needs. Please take a moment to complete the following information.

    Name:

    Email:

    Date:

    Occupation:

    Employer:

    Primary care physician/clinic:

    Reason for eye exam:

    Date of last eye exam:

    Pregnant/Nursing: YesNo

    Review of Systems

    If yes, please indicate specific condition

    Eyes (Glaucoma, Cataract, Lazy Eye, Retina Problems, Headaches, Dryness, Itching, Infections, Double Vision, Floaters, Loss of Vision, Other): YesNo

    Constitution (Cancer, Fatigue Syndrome, Other): YesNo

    Ear/Nose/Throat (Hearing Loss, Sinusitis, Dry Mouth, Laryngitis): YesNo

    Neurological (Multiple Sclerosis, Epilepsy, Tumor, Stroke/CVA, Migraine, Other): YesNo

    Psychiatric (Depression, Anxiety, Bipolar Disorder, Other): YesNo

    Cardiovascular (High Blood Pressure, Heart Disease, Congestive Heart Failure, Other): YesNo

    Respiratory (Asthma, Bronchitis, Sleep Apnea, Other): YesNo

    Gastrointestinal (Crohn's, Colitis, Acid Reflux, Other): YesNo

    Genitourinary (Kidney Disease, Prostate Disease, Other): YesNo

    Musculoskeletal (Arthritis, Fibromyalgia, Ankylosing Spondylitis, Other): YesNo

    Integumentary (Eczema, Rosacea, Psoriasis, Shingles, Other): YesNo

    Endocrine (Type 1 or Type 2 Diabetes, Thyroid Dysfunction, Other): YesNo

    Lymphatic (Anemia, Leukemia, Other): YesNo

    Immune/Allergy (Rheumatoid Arthritis, Lupus, Sjogren's, Environmental Allergies): YesNo

    Medication Allergies? (Please list names): YesNo

    List of current medications (including eye drops):

    Social History

    Do you use nutritional supplements (vitamins, etc.)? YesNo

    Do you drink alcohol? NoOccasional1/day2-3/day4+/day

    Do you use tobacco products? NoOccasional1/2 pack/day1 pack/day1+ packs/day

    Please list any hobbies/interests:

    Family History

    Family Medical History - If yes, please indicate relationship to patient (only immediate family members)

    High Blood Pressure: YesNo

    Diabetes: YesNo

    Cancer: YesNo

    Thyroid: YesNo

    Other: YesNo

    Family Ocular History - If yes, please indicate relationship to patient (only immediate family members)

    Glaucoma: YesNo

    Retinal Detachment: YesNo

    Cataracts: YesNo

    Macular Degeneration: YesNo

    Blindness: YesNo

    Lazy Eye: YesNo

    Glasses/Contact Lens History

    Do you currently wear glasses? YesNo
    If yes, how often? Full timePart time

    Type of glasses? Single visionBifocalTrifocalProgressive (no line bifocal)

    Do you wear contact lenses? YesNo
    If no, are you interested in trying them? YesNo

    Brand of contact lenses?

    What contact lens solution do you use?