Dr. Jack Rountree, Therapeutic Optometrist, Glaucoma Specialist

Patient Information Insurance Information

Please note that Eye Exam coverage does not automatically cover the contact lens fitting fee. Fitting fee is an annual reoccurring fee. Contact lens fitting is Today’s Date ______good for 3 visits or 60 days, whichever occurs first. X______initial here. Last ______

First______MI__Title______Vision Insurance______

Street______Primary Name______

City______State______Primary Member ID______

Zip Code______Subscriber D.O.B.______

Home Phone______Primary Medical Insurance______

Daytime Phone______Primary Name______Primary Member ID______Gender M F Marital Status______Primary D.O.B.______Date of Birth______Age______

Patient SSN______

Employer (or School)______Patient Medical History

Occupation (or Grade)______

Spouse (or Parent’s name)______***Please note***

Spouse (or Parent’s work)______We do retinal photos on everyone. Because many diseases and disorders can be

E-mail Address______identified through this test, it is an essential part of your medical eye exam

What is the Major Purpose of this visit? every year. X______initial here.

______Date of Last Eye Exam______

Are you interested in Lasik? Yes ( ) No ( ) Name of Eye Doctor______Name of Family Physician______Any problems with your current glasses or contacts? Date of Last Physical Check-up ______

______Please list any surgeries you have had (Eye, Body).

______

How did you find out about us? ______

______The information in this confidential case history form is critical to the evaluation of your vision and health.

Vision History Patient Medical History

Are you experiencing or have been diagnosed or treated for any Have you ever been diagnosed or treated for the following health of the following? problems? Yes No

( ) Blurry Vision (near or far) ( ) Burning Urinary Problems ( ) ( ) ( ) Cataracts ( ) Corneal Abrasion High Blood Pressure ( ) ( ) ( ) Crossed Eye/Eye turn ( ) Double Vision Skin Disorders ______( ) ( ) ( ) Eye Infection ( ) Eye Injury Kidney ( ) ( ) ( ) Flash of light (sudden onset) ( ) Floaters

( ) Glaucoma ( ) Grittiness Muscle/Bone ( ) ( )

( ) Headaches ( ) Iritis/Uveitis Neurological ( ) ( )

( ) Itchiness ( ) Lazy Eye Psychological ( ) ( )

( ) Macular Degeneration ( ) Occasional Dryness Sinus ( ) ( ) ( ) Retinal detachment ( ) Sunlight Sensitivity Throat Infections ( ) ( ) ( ) Tearing ( ) Trouble seeing at night Thyroid Infections ( ) ( ) Approximate Height ______Weight ______Unusual weight losses/gains ( ) ( ) Allergies to Meds ( ) Y ( ) N Please list ______Seizures ( ) ( ) Do you use cigarettes/tobacco, alcohol, or other substance?

If so how much/how often? ( ) Y ( ) N______Family Medical/Eye History (Check all that apply)

Over the counter Meds (Eye drops, allergy, pain, sleep aid, etc) ______Is there a family medical history of any of the following:

Current RX Medication (Blood pressure, cholesterol, birth control, ( ) Yes (Please check boxes) ( ) No etc.)______Relationship: Are you Pregnant or Nursing? ( ) Yes ( ) No (Who in the family and which side Mom or Dad’s?) Have you ever been diagnosed or treated for the following health problems? Yes No Blindness ( )______Allergies (medical or seasonal) ( ) ( ) Cataracts ( )______Arthritis (Rheumatoid) ( ) ( ) Corneal Problems ( )______Bronchitis ( ) ( ) Retinal Problems ( )______Cancer ______( ) ( )

Elevated Cholesterol ( ) ( ) Glaucoma ( )______

Diabetes Type I or II (circle one) ( ) ( ) Macular Degeneration ( )______

Digestive ( ) ( ) Lazy Eye ( )______

Ears/Nose/ Throat ( ) ( ) Heart Disease ( )______Eczema/Rashes ( ) ( ) Diabetes ( )______Fatigue ( ) ( )