accuvision.com
Close Window
Select Office
Chicago Michigan Avenue
Gurnee
Round Lake Beach
Lindenhurst
Mundelein
Schaumburg
Wauconda
Patient Status
New Patient
Current Patient
Not a Patient
PATIENT MED-HISTORY
Birth Month
January
February
March
April
May
June
July
August
September
October
November
December
Birth Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Birth Year
Age
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Tel-(
)
-
Alt Tel-(
)
-
SS#
-
-
Gender
Male
Female
Marital Status
Single
Married
Divorced
Widowed
Last Exam
Never
Not Applicable
Don't Know
1 Month ago
2 Months ago
3 Months ago
6 Months ago
9 Months ago
1 Year ago
1¼ Years ago
1½ Years ago
1¾ Years ago
2 Years ago
2¼ Years ago
2½ Years ago
2¾ Years ago
3 Years ago
3¼ Years ago
3½ Years ago
3¾ Years ago
4 Years ago
4¼ Years ago
4½ Years ago
4¾ Years ago
5 Years ago
5¼ Years ago
5½ Years ago
5¾ Years ago
Too Long ago
Exam Type Wanted
Check Up
For Glasses
For Contact Lenses
For Glasses & Contacts
LASIK Consultation
Medical Consultation
Exam Follow Up
Contact Follow Up
Surgical Follow Up
Not Sure
Do you currently wear:
Glasses
YES
NO
Type
Distance
Near
Both
MonoVision
Contact Lenses
YES
NO
Type
Soft
Rigid
Both
CRT
Low Vision Aids
YES
NO
Do you currently have or have you ever had any of the following:
Eye Surgeries
YES
NO
Eye Injuries
Eye Infections
Amblyopia
Cataracts
Dry Eyes
YES
NO
Light Sensitivity
Pain
Glaucoma
Lazy Eye
Macular Degeneration
YES
NO
Eye Turn In / Out
Reading Problems
Tracking Problems
Other
Do you Have:
.
YES
NO
Diabetes
# of Years
less than 1
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
11 Years
12 Years
13 Years
14 Years
15 Years
16 Years
17 Years
18 Years
19 Years
20 Years
21 Years
22 Years
23 Years
24 Years
25 Years
more than 25
High Blood Pressure
# of Years
less than 1
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
11 Years
12 Years
13 Years
14 Years
15 Years
16 Years
17 Years
18 Years
19 Years
20 Years
21 Years
22 Years
23 Years
24 Years
25 Years
more than 25
.
YES
NO
Headaches
When or how often
When I do close work
Intermittent
when I day drive
When I night drive
Driving day or night
In the morning
In the afternoon
At the end of the day
less than once a day
Once a day
Twice a day
More than twice a day
All the time
Can't remember
.
Medication
- List any Medications:
Allergies
- List any known Allergies:
Are you currently taking
YES
NO
prescription or non-prescription drugs?
Do you currently have any Allergies
YES
NO
known or perceived?
Do you have problems with any of these systems?
- Please check all that apply
Allergic / Immunologic
YES
NO
Arthritis
Blood / Lymph
Cardiovascular Heart Disease
Ear / Nose / Throat
Endocrine Glands
Gastrointestinal
Integument Skin
Kidney Problems
YES
NO
Musculature
Nervous
Psychiatric
Respiratory
Skeletal Bones
Thyroid Problems
Other (explain bottom of page)
Do you use
-
Please select all that apply
Cigarettes?
YES
NO
Packs per Day
½ Pack a Day
1 Pack a Day
1½ Packs a Day
2 Packs a Day
2½ Packs a Day
3 Packs a Day
More than 3
Alcohol?
YES
NO
Frequency
Social Drinker
Occasionally
1 Drink a Day
2 Drinks a Day
3 Drinks a Day
4 Drinks a Day
5 Drinks a Day
More than 5
1 Drink a Week
2 Drinks a Week
3 Drinks a Week
4 Drinks a Week
5 Drinks a Week
More than 5
1 Drink a Month
2 Drinks a Month
3 Drinks a Month
4 Drinks a Month
5 Drinks a Month
More than 5
Other substances?
YES
NO
Substances
Prescribed substances
Un-prescribed substances
Family Eye History
- Anyone in patient's family (blood relative) had any of the following?
Cataracts
YES
NO
Cornea Disease
Diabetes
Glaucoma
YES
NO
Lazy Eye
Macular Degeneration
Retina Disease
YES
NO
High Blood Pressure
Other Eye Disorders
Your Surgical History
- List any type of surgery and dates of surgery
Occupation
- If applicable, what type of work do you do?
Hobbies
- List any hobbies or sports you participate in
V
ision Correction Preferences
,
Interests
- Put a check in any boxes that interests you
LASER VISION CORRECTION
Laser vision correction
LASIK with the new Wavefront
®
technology
C
ONTACT LENSES
Contacts that are comfortable ALL day long
Disposable Contact Lenses
CRT (Corneal Refractive Therapy) a non-surgical alternative to LASIK
Contact Lenses to replace glasses
Contact lenses that I can sleep in, wake up, and see. (a non-surgical alternative to LASIK)
Contact lenses that require no care, to be worn for specific occasions
Contact Lenses that correct astigmatism
Contact Lenses that change eye color. (Even without prescription)
Bifocal Contact Lenses
EYEGLASSES
Extra thin and light eyeglass lenses
Anti-reflective (Glare-Free) lenses. Reduce eyestrain. Great for night vision & computers
Designer frames
Frames that weigh less than a feather
Invisible bifocal (No-Line progressives)
Lenses that auto-adjust to comfortable shades of color, based on the light (In/Out door)
Cosmetic tinted lenses - also tones down harsh indoor light for those who are light sensitive
Specialty Glasses - Sports Frames, Snorkel/Scuba masks, swim, ski Motorcycle, Etc.
SUN
GLASSES
UV (Ultra-Violet) light protection
Polaroid lenses -considerably reduces sun & reflective glare, & eliminates horizontal reflections
Sunglasses to wear with Contact Lenses
C
HILDREN'S VISION
I need to know at what age should children have their first eye exam
I need to know at what age can children wear Contact Lenses
Protective eyeglasses for sports
I need to know the difference between Screenings & eye examinations
Other Information
- Please elaborate on any information or from any "Other" box above.