Patient Info Sheet Visual InformationName* First Last Please check all that you are currently experiencing:* Blurry far away Blurry up-close Floaters or spots Eyes water easily Amblyopia (lazy eye) Loss of vision Strabismus (crossed eyes) Infection of Eye or lid Retinal detachment Night vision problems Headaches Loss of Side Vision Itching Dry Eyes Sandy/gritty Eyes burn Pain in or around Redness Fluctuating vision Drooping Eyelid(s) Foreign body sensation Eye Stain/tired eyes Light Sensitivity Haloes Mucous Discharge None of the above Lifestyle FactorsSports/Activities Are you interested in contact lenses?* Yes No Do you have a pair of back-up glasses?* Yes No Do you have a pair of prescription sunglasses?* Yes No Does road glare/night vision bother you?* Yes No Do you have visual problems while on a computer?*(eye strain/tilt your head) Yes No How many hours per day do you work on the computer? I stopped wearing glasses* Yes No Do you drink alcohol?* Yes No If so, how many drinks per day? Do you smoke?* Yes No If so, how often during the day? Contact Lens RatingI am interested in wearing contacts* Yes No Rate how your contacts feel immediately after you first put them in:1 being poor, 5 being excellent 1 2 3 4 5 Indicate the time you put your contacts in: Rate how your contacts feel just before you take them out:1 being poor, 5 being excellent 1 2 3 4 5 Indicate the time you take your contacts out: Do you use contact lens rewetting drops? Yes No If so, how often during the day? I stopped wearing contacts* Yes No Health InformationDo you or anyone in your family have a history of:(please check all that apply)Diabetes* No Self Family Glaucoma* No Self Family Cataract* No Self Family Macular Degeneration* No Self Family High/Low Blood Pressure* No Self Family High/Low Cholesterol* No Self Family Please check off any current conditions you suffer from:*(please check all that apply) Chronic fever, unexpected weight loss/gain, fatigue Ear/nose/throat problems (eg. Hearing loss, sinus problems, sore throat) Heart problems (eg. Chest pain, irregular heartbeat, swelling of feet, cold hands or feet) Respiratory problems (eg. Shortness of breath, wheezing, coughing) Gastrointestinal problems (Heartburn, abdominal pain, diarrhea, vomiting) Genitourinary problems (eg. Painful urination, blood in urine, sex organ problems) Musculoskeletal problems (eg. Muscle aches, joint pain, swollen joints) Skin problems (eg. Rashes, excessive dryness, growths or lumps) Neurological problems (eg. Numbness, weakness, headaches, “blackouts”) Psychiatric problems (eg. Depression, anxiety) Endocrine problems (eg. Frequent urination, thirst, feeling hot or cold all the time) Blood/Lymph problems (eg. Bruising, weakness, unusual paleness, swollen glands) Immune problems (eg. Frequent infections, allergic reactions to foods, dust, pollens) None of the above Please list any medications and the dosage that you are currently taking:MedicationDosage Are you allergic to any medications? NOTE: Your insurance plan is a contract between you and your insurance company. Our office cannot be responsible for determining your benefits. You must notify us if your insurance plan covers routine vision prior to any services. If you are not sure if your plan covers routine vision, payment is due at the time services are rendered. If your plan requires a referral, it is your responsibility to obtain one from your primary care doctor prior to your appointment. If your insurance denies the charges incurred, they are your responsibility. Assignment of Benefits: I hereby consent to such treatment and patient care, which may be considered necessary or advisable as a patient of Adriana Palumbo, OD for services rendered. I understand that I am ultimately responsible for all charges on services rendered, whether or not paid by insurance.Signature or Patient or Guardian*Date* MM slash DD slash YYYY In case of divorced or separated parents, our policy is that the parent bringing the child into our office is responsible for payment of all fees.