Laser Center

Please Print Clearly Date

Last Name First Name MI Birthday Age Male Female

Current Address Street City State Zip Code

Home Telephone E-Mail

Work Telephone Cell

Employer Occupation

Employers Address

Emergency Contact Telephone # Relationship

Social Security Number (SSN) Married , Single , Widow , Other

HOW DID YOU HEAR ABOUT US / WHO REFERRED YOU?
Physician, Optometrist, Friend / Relative , Yellow Pages, Facebook, Our Website,
Google, Yahoo, TopDoc, ZocDoc, Angie’s list, Yelp, Other
Your Physician: Name MD/DO Address
City State Zip Phone
Your Optometrist: Name MD/DO Address
City State Zip Phone

What medications are you currently taking?

Eye medications?
Allergies?
How old are your glasses?
How often does your prescription change?
Do you wear contact lenses? Yes No
If yes, What type? Soft daily , Soft Toric , Soft extended , Gas Permeable
Do you sleep in your contact lenses? Yes No
If you wear reading glasses, have you tried Monovision Contact Lenses? Yes No
How long have you worn contact lenses?
Please list any history of eye problems or eye surgery in yourself or a member of your immediate family?

What is the reason for your visit?

How concerned are you with the appearance of any fine lines or wrinkles on your face?
Not Concerned ,, Somewhat Concerned ,, Very Concerned

Medical History:
Present Review of Systems (Do you currently have any problems in the following areas?)

High blood pressure ( yrs)	Y	N	Ear, Nose, Mouth, Throat	Y	N
Heart disease	Y	N	Stroke (when )	Y	N
Heart Pain	Y	N	Poor Circulation	Y	N
Diabetes ( yrs)	Y	N	Bones, joints, muscles	Y	N
Rheumatoid Arthritis	Y	N	Constitutional (fever)	Y	N
Weight Loss/Gain	Y	N	Joint Pain	Y	N
Breathing problems	Y	N	Endocrine	Y	N
Skin problems	Y	N	Kidney Problems	Y	N
Headaches	Y	N	Migraines	Y	N
Cancer (type )	Y	N	Prostate disease	Y	N
Depression	Y	N	Do you take Flomax?	Y	N
Neurological Systems	Y	N	Drooping Eyelids	Y	N
Psychiatric	Y	N	Refractive Surgery	Y	N
Allergic/Immunologic	Y	N	Keratoconus	Y	N
Sinus congestion	Y	N	Eye Injury	Y	N
Dry throat/mouth	Y	N	Cataracts	Y	N
Chronic cough	Y	N	Macular Degeneration	Y	N
Chronic Bronchitis	Y	N	Retinal Problems	Y	N
Asthma	Y	N	Crusty eyelashes	Y	N
Emphysema	Y	N	Glaucoma	Y	N
Gastrointestinal (stomach)	Y	N	Crossed Eyes	Y	N
HIV positive	Y	N	Vision Loss	Y	N
Hay fever	Y	N

Other

Past Medical History:

List all surgeries & hospitalizations you have had in the past

Social History:
Do you use tobacco products? Yes No If so: packs per day
Do you drink alcoholic beverages Yes No If so: drinks per week

Family History: (list any medical problems in your family)
Glaucoma , diabetes , high blood pressure , crossed eyes , lazy eye , keratoconus , retinal problems , cancer
arthritis , gout , heart disease , kidney disease , lupus , stroke , thyroid , lung problems
Other

Is there anything else we should know about you and your general health?

Patient Signature _____________________________________________ Date

Golden Eye Surgeons and Consultants

Patient Information