CRYSTAL EYE CARE, JEFF CHUH, OD
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​703-413-9001
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Patient Forms

WELCOME TO CRYSTAL EYE CARE, Jeff Chuh, OD.
 PATIENT INFORMATION
  
 Date: ___________________
 Name: _______________________________________________________________________
 Address: ______________________________________________________________________
                                                                               Apt #                 City                  State               Zip Code
  
 Phone #s: Home: _________________ Work: ________________ Email: ___________________
 Date of Birth: ______________________________
 last 4 digits of SS#: ____________________________(need for certain insurances)
 Occupation / Grade (if attending school): ______________________________________
 Employer / School: _______________________________________________________
 Whom may we thank for referring you? _______________________________________

 EYE HEALTH HISTORY
 Reason for visit:  _________________________________________________________
                             _________________________________________________________
  
 Date of last eye exam: _____________________ Dilated?  Yes   No   Not sure
 Name of eye doctor/office: __________________________
 Do you frequently experience/have (please check all that apply)
  Blurred Vision  Distance                                     Night Vision, Poor
  Blurred Vision  Near                                           Light Sensitivity
  Distorted Vision                                                    Floaters or Spots
  Double Vision                                                       Seeing Halos
  Burning Eyes                                                         Seeing Flashes
  Itchy Eyes                                                              Dizziness
  Watery Eyes                                                          Headaches
  Painful Eyes                                                          Tired Eyes
  Eye Infection                                                         Twitching Eyelid
  Discharge From Eyes                                            Excessive Blinking
  Red Eyes                                                               Excessive Squinting
  Dry Eyes                                                               Eye Strain
  Gritty, Sandy Eyes                                                Other ________________________
                                                                                            __________________________
 Do you presently wear prescribed glasses?     Yes     No       Worn before
       All the time                           Occasionally               
       Reading           Driving          TV          Computer       Other _____________
 How old are your glasses? ___________
  
 Do you presently wear contact lenses?    Yes       No        Worn before
      If so, what type?         Soft     Rigid Gas Permeable    Color
      Brand / Prescription of contacts: ____________________________________     
      Wearing hours / Day: _______________hours / day   
      Wear overnight?:   No    Yes  How Often: ___________________
      How often do you replace contact lenses?   :______________________________
 
 If you or a blood relative have experienced any of the following, check all that apply and please indicate who:
  Glaucoma_________________________   Macular degeneration _______________                       
  Loss of Vision______________________  Eye Injury________________________
  Temporary Loss of Vision ____________  Eye Surgery_______________________
  Cataract ___________________________ Amblyopia/ Lazy Eye_______________
  Color Vision, Poor___________________ Retina detachment _________________
  Other Eye Disease  _____________________________________________________
  
 Does your job/school require the use of a computer?     Yes        No
 How many hours per day? _________________________________
 Any problem with computer: _____________________________________________
             Glare          Eye Strain      Watery Eyes       Headache   
 HEALTH HISTORY
 How would you describe your general health:   Excellent         Average        Poor
 Physician's name: _____________________________   Date of last visit: _____________
 Dr's telephone numbers:  ____________________________________
 Do you have problems with any of these systems? (Please circle all that apply)
 Gastrointestinal          Y / N       Nervous                       Y / N         Eyes             Y / N
 Ears/Nose/Throat       Y / N       Genitourinary              Y / N          Mental         Y / N
 Cardiovascular           Y / N       Muscle                         Y / N         Endocrine    Y / N
 Respiratory                Y / N        Bone / Joint                 Y / N          Skin     Y / N           
 If you or a blood relative have any of the following, check all that apply and indicate who:
  High Blood Pressure________________        Tuberculosis_____________________
  Diabetes__________________________        Emphysema_____________________
  Cancer___________________________         Epilepsy________________________
  Thyroid problems__________________         Hay Fever_______________________
  AIDS/ HIV_______________________          Kidney Disease__________________
  Arthritis_________________________           Lupus__________________________
  Asthma _________________________          
  Heart Condition___________________          Are you pregnant? _______________
  Shingles_________________________          Do you smoke?__________________
  Skin Conditions___________________          Excessive Alcohol use____________      
  Stroke___________________________         Chemical Dependency_____________
  Hepatitis ( Type ____)_____________           Other _________________________

                      MEDICATIONS                                        ALLERGIES
 List medications you are currently taking,           List your allergies to  medications      
 including eye drops.  How often are you                       substances:
 taking, and reason for taking?                                    
__________________________________       __________________________________                         __________________________________      __________________________________
__________________________________      __________________________________
__________________________________      __________________________________
__________________________________      __________________________________
__________________________________      __________________________________
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Contact Us
1654 Crystal Square Arcade
Arlington, Virginia 22202
Phone: 703-413-9001
Email: JeffChuh@yahoo.com
Fax: 703-552-1334
Business Hours
Monday - Saturday  9:30 -4:00
Sunday:    Closed


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