Hartland Eye Care - Optometrist In Hartland, MI USA

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Welcome To Our Office

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First Name *

Last Name *

Address

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

EMAIL ADDRESS

Date of Birth

Employer/ Occupation

Marital Status

How did you hear about our office?

Doctor ReferralFriendYellow PagesSign on BuildingInsurance CompanyWebpage

Insurance Information

Primary Vision Insurance Company Name

ID #

Primary Medical Insurance Company Name

ID #

Medical History

Have you had any of the following health problems?

GastrointestinalEars/Nose/ThroatCardiovascularRespiratoryHigh Blood PressureNeurologicalUrinaryMuscles/BonesSkinEyesEndocrineBlood/LymphAllergic/ImmunologicalHeadachesMental

List your current medications and what they are for

Are you a diabetic?

Please list any medication allergies

Please list any surgeries

Your Primary Care Physician

Personal Eye Information

Date of last vision examination

Are you having any of these eye symptoms?

RednessDrynessSandy or Gritty SensationItchingExcess watering or tearingExcess mucous dischargeBlurred VisionSensitive to smokeSensitive to windSensitive to glareSensitive to air conditioners or heatersSensitive to lightSensitive to Contact Lenses

If you checked anything above, are your symptoms worse

Do you ever wear?

Prescription GlassesComputer GlassesPrescription SunglassesNon Prescription SunglassesSoft Contact LensesHard Contact LensesReading Glasses

Do you use a computer?

YesNo

Number of hours per day?

Are there any times when you wish your vision was better please explain:

Family History

Does any of your immediate family have any of these conditions?

High Blood Pressure

YesNo

If yes who?

Diabetes

YesNo

If yes who?

Glaucoma

YesNo

If yes who?

Macular Degeneration

Yes No

If yes who?

Retinal Detachment

YesNo

If yes who?

Cataracts

YesNo

If yes who?

Tell us why you are here today:

Check all that apply

Routine ExamNew GlassesNew Glasses if prescription changeNew ContactsContact Lens FittingEye Health problemAcademic ProblemsOther

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Welcome To Our Office

Insurance Information

Medical History

Personal Eye Information

Family History

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