Dr. Traer G. Caywood | Dr. Rick W. Winward

OPTOMETRY

Name:
Street Address:
City/State/Zip:
Gender: Male Female
Date of Birth: -- mm/dd/yy
SS#:
Occupation:
Last Eye Exam Date: -- mm/dd/yy
Last Eye Exam Location:
Name of Medical Doctor:
Medical Doctor Phone:
Last Medical Exam:
Today's Date: -- mm/dd/yy

Which office do you prefer to visit? Provo Springville
Work Phone:
Home Phone:
FAX:
E-mail:
Head of Household:
Employer:
Emergency Contact:
Emergency Contact Phone:
Were you referred to us? Yes No
By whom?

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Insurance Information

Primary Insurance:
Group:
Policy Holder:
Policy Holder SS#:
Employer of Insured
Secondary Insurance:
Medicaid Part B #:
Policy Holder:
Policy Holder SS#:
Medicaid #:
Policy Holder:
Policy Holder SS#:

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Medical History

Do you have any seasonal or drug allergies? Yes No     If yes, explain:
List any medications you take, including eye drops and over the counter medications:
List all major injuries, surgeries, and/or hospitalizations you have had, including eye surgeries:
Note any of the following that you currently have or have had:  
Disease/Condition

Yes          No

 Disease/Condition

Yes          No

 Disease/Condition Yes     No
High Blood Pressure

         

Floaters           Retinal Detachment     
Diabetes

         

Double vision           Macular Degeneration     
Thyroid Disorder

         

Cataracts           Lazy Eye/Amblyopia     
Heart Disease           Iritis           Flashes of light     
Glaucoma           Dry eyes           Extreme nearsightedness     
Crossed Eyes           Eye injury           Blindness     
Eye infection           Droopy eyelid           Other     
Are you pregnant and/or breastfeeding? Yes No        If pregnant, how many weeks?
Do you wear glasses? Yes No   If yes, when do you wear them?   Full time     Reading     Computer     Driving
Do you wear contact lenses?Yes No  If yes, what type?  Rigid/Hard   Soft   Bifocal   Toric   Extended wear
   Disposable (brand    How often do you replace them?    Are your contacts comfortable? Yes No

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Social History (this information is kept strictly confidential)

Do you drive? Yes No          Marital Status Married     Single     Divorced     Widowed
Do you use tobacco products?Yes No    If yes, type/amount/how long:
Do you drink alcohol?             Yes No    If yes, type/amount/how long:
Do you use illegal drugs?        Yes No    If yes, type/amount/how long:
Have you ever been exposed to or infected with: HIV     Hepatitis     Gonorrhea     Syphilis

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Family History
Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions:

Disease/Condition

Yes    No

 Relationship Disease/Condition

Yes    No

 Relationship
High Blood Pressure

   

Retinal Detachment    
Diabetes

   

Crossed/Lazy Eye    
Glaucoma     Macular degeneration    
Cataracts     Extreme nearsightedness     

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Review of Systems
Do you currently, or have you had any problems in the following areas::

System

Yes    No

System

Yes    No
Constitutional (fever, weight loss/gain)

   

Musculoskeletal (arthritis, muscles, bones)    
Eyes

   

Integumentary (skin, breast)    
Ears, Nose, Mouth, Throat     Neurological (headaches, numbness)    
Cardiovascular/Vascular (heart)     Psychiatric (mental, depression, anxiety)    
Respiratory (lungs)

   

Endocrine (diabetes, thyroid)

   

Gastrointestinal (stomach, intestines, liver)

   

Lymphatic/Hematologic (blood, lymph node)

   

Genitourinary (kidneys, urinary/reproductive tract)

   

Allergic/Immunologic (allergies, immune)

   

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Mark any of the following that you would like more information on:

Contact lenses Colored contacts Laser vision correction
Disposable contacts Bifocal contacts Vision and reading problems of children
Contacts for dry eyes No line bifocals Lazy eye
Contact lenses for astigmatism Special lens designs for computer users Light weight glasses and thinner lenses
Lenses for skiing, scuba diving, biking, hunting, or sports