Advanced Technology Eye Treatments at Raleigh Eye Care Center

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Patient Information

Patient name (First MI Last): *

Your name:

Relationship to patient:

Home phone: *

Work phone: *

Email address: *

Preferred contact: *

Email Phone

Birthdate (mm/dd/yyyy): *

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Sex:

Male Female

Insurance company:

Primary care physician:

Medical History

List any medications you take:

List all major illnesses or injuries (diabetes, high blood pressure, emphysema, heart attacks, etc):

Do you have any allergies to medications? Yes No

If yes, please list the medications:

List any surgeries you have had:

List all eye illnesses or injuries (crossed/lazy eye, cataract, glaucoma, macular degeneration, abrasions, etc.):

Do you currently have any problems in the following areas?
	Yes No	If yes, please explain:
General / Constitutional (fever, weight loss, other)
Ears, Nose, and Throat (cold, sinus, chronic cough)
Cardiovascular (heart, vessels, etc.)
Respiratory (asthma, emphysema, etc.)
Gastrointestinal (ulcers, intestinal disease, etc.)
Genital, Kidney, Bladder
Skin (rosacea, skin cancer, psoriasis, etc.)
Neurological (MS, stroke, seizures, etc.)
Psychiatric (anxiety, depression, etc.)
Endocrine (diabetes, thyroid, etc.)
Blood / Lymph (bleeding disorder, high cholesterol, anemia, etc.)
Allergic / Immunologic (lupus, hay fever, rheumatoid arthritis, etc.)

Do you have a family history of:
	Yes No	Relationship to patient:
Blindness
Glaucoma
Macular degeneration
Diabetes

Social History
Current Occupation:
Marital Status:	Single Married Widowed Divorced
Do you live:	Alone With spouse With relatives Retirement facility Other:
Do you smoke?	Yes No
If so, how much?	packs / day
Do you drink alcohol?	Yes No
If so, how much?	drinks / day

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