PATIENT LOG  ( confidential ) Kim Admire O.D. 555 Broadway  Ste 1021

  Chula Vista, CA 91910 

    

 Name:________________________________________________

    

 Address:______________________________________________

               

  ______________________________________________

   

 Phone:_____________________     Email:______________________

  

 Date of Birth:_________________  Insurance:_____________ ID#__________________           

     

 Primary Care Doctor:___________________________________________________________       

 

What is your Occupation?:______________________________________________________________

 

Main Reason for visit:___________________________________________________________________

 

Do you wear :  Glasses _____   Contact Lenses _____   How often do you use a computer ____________

 

List any activities which may have specific visual requirements

__________________________________________________

 

Have you ever had :  Eye Injury_________    Eye Surgery____________  Eye Disease _______________

 

Do you or does a Blood Relative have a history of any of the following conditions?

 

Diabetes_________   High Blood Pressure________   Thyroid________  Allergy_____________

 

Glaucoma________   Heart Disease__________   Reaction to any Medication________________

                                                                                                                                                           

Please List Any Medications you are taking__________________________________________________________________

 

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