HOLLYWOOD VISION CENTER

New Patient Form

Date

Patient Name

Age

Date of Birth

Home Address

City

State

Zip

Home Phone

Referred By

Driver License State

Driver License Number

Social Security Number

E-Mail Address

Employer

Occupation

Business Address

City

State

Zip

Business Phone

Spouse's Name

Spouse's Employer

Business Address

City

State

Zip

Business Phone

MEDICAL HISTORY

Date of last vision exam

Previous Eye Doctor

Past injury or surgery to eyes?

Please Describe

List any of the following
that you have had:

 Crossed Eyes

 Lazy Eye

 Drooping Eyelid

 Prominent Eyes

 Glaucoma

 Retinal Disease

 Cataracts

 Eye Infections

 Eye Injury

Have you had a physical exam
in the last 12 months?

 Yes     No

Physician's Name

Please describe if there were any significant findings

List any medications you are taking

Are you allergic to any medications?

 Yes     No

If yes, please list

Please list an emergency contact who is not living with you:

Name

Phone

Relationship

FAMILY HISTORY
Please note any family history (parents, grandparents, siblings; living or deceased) for the following:

DISEASE / CONDITION     

RELATIONSHIP TO YOU

 Blindness  

 Cataract   

 Crossed Eyes   

  Glaucoma

  Macular Degeneration

 Retinal Detachment / Disease

  Cancer

  Diabetes

  Heart Disease

  High Blood Pressure

  Kidney Disease

  Lupus

  Thyroid Disease

  Neurosurgery

  Stroke

  Accident / Head Trauma

  Other