<p> Dr. Jack Rountree, Therapeutic Optometrist, Glaucoma Specialist</p><p>Patient Information Insurance Information</p><p>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 ______</p><p>First______MI__Title______Vision Insurance______</p><p>Street______Primary Name______</p><p>City______State______Primary Member ID______</p><p>Zip Code______Subscriber D.O.B.______</p><p>Home Phone______Primary Medical Insurance______</p><p>Daytime Phone______Primary Name______Primary Member ID______Gender M F Marital Status______Primary D.O.B.______Date of Birth______Age______</p><p>Patient SSN______</p><p>Employer (or School)______Patient Medical History</p><p>Occupation (or Grade)______</p><p>Spouse (or Parent’s name)______***Please note***</p><p>Spouse (or Parent’s work)______We do retinal photos on everyone. Because many diseases and disorders can be </p><p>E-mail Address______identified through this test, it is an essential part of your medical eye exam </p><p>What is the Major Purpose of this visit? every year. X______initial here.</p><p>______Date of Last Eye Exam______</p><p>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 ______</p><p>______Please list any surgeries you have had (Eye, Body).</p><p>______</p><p>How did you find out about us? ______</p><p>______The information in this confidential case history form is critical to the evaluation of your vision and health.</p><p>Vision History Patient Medical History</p><p>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</p><p>( ) 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</p><p>( ) Glaucoma ( ) Grittiness Muscle/Bone ( ) ( )</p><p>( ) Headaches ( ) Iritis/Uveitis Neurological ( ) ( )</p><p>( ) Itchiness ( ) Lazy Eye Psychological ( ) ( )</p><p>( ) 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? </p><p>If so how much/how often? ( ) Y ( ) N______Family Medical/Eye History (Check all that apply)</p><p>Over the counter Meds (Eye drops, allergy, pain, sleep aid, etc) ______Is there a family medical history of any of the following:</p><p>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 ______( ) ( )</p><p>Elevated Cholesterol ( ) ( ) Glaucoma ( )______</p><p>Diabetes Type I or II (circle one) ( ) ( ) Macular Degeneration ( )______</p><p>Digestive ( ) ( ) Lazy Eye ( )______</p><p>Ears/Nose/ Throat ( ) ( ) Heart Disease ( )______Eczema/Rashes ( ) ( ) Diabetes ( )______Fatigue ( ) ( ) </p>