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?