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?
__________________________________ __________________________________ __________________________________ __________________________________
__________________________________ __________________________________
__________________________________ __________________________________
__________________________________ __________________________________
__________________________________ __________________________________
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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