Better Vision, Better Life
(770) 436-9123 | Fax: (770)436-9193
735 Windy Hill Road, Smyrna, GA 30080
info@youreyesrus.com

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Welcome to our office!

  Date :
  Name : *
  Street :
  City/State/Zip :
  Phone :
  Date of Birth : *
  Sex : Male Female
  E-mail : *
  VERY IMPORTANT! NEW PATIENTS ONLY!
  How did you hear about our office? : *
  HIPAA PRIVACY ACT:
  I have read the copy of the HIPAA PRIVACY
ACT (see clip board), and agree to its
terms. Please sign below. *

Date *
  To read Privacy Act click here
  If patient is under 18 years of age:
  I hereby give constent for Eyes-R-Us Family Optical to treat (Child's name) *
  (Payment is expected at the time services are rendered)
  Do you have vision insurance? : Yes No
  If yes, Name of the Company : *
  Do you have medical insurance? : Yes No
  If yes, Name of the Company 1 : *
  If yes, Name of the Company 2 : *
  Insured's Information:
  Name: : *
  Date: : *
  SS (last4) : *
  Relationship to Patient: : *
  (please present insurance card(s) to front desk)
  Social History
  Do you smoke? : Yes No
  Do you drink? : Yes No
  Are you pregnant? : Yes No
  Medical History Questionnaire
  Family Physician : *
  Current Medications : *
  Allergic to any Medications? : Yes No
  If Yes, which medications? : *

 
  Do you currently have any problems in the following areas?
  General/Constitutional (fever, weight los s, other)   Yes No
  Ears, Nose, Throat
(sinus, ear infection, chronic cough, dry mouth, etc.)		   Yes No
  Cardiovascular
(heart, vessels, etc.)		   Yes No
  Respiratory
(asthma, emphysema, etc.)		   Yes No
  Gastrointestinal
(stomach ulcers, intestinal disease, etc.)		   Yes No
  Endocrine
(diabetes, hypothyroid, etc.)		   Yes No
  Skeletal
(osteoporosis, arthritis, etc.)		   Yes No
  Skin
(acne, warts, skin cancer, etc.)		   Yes No
  Neurological/Psychiatric
(anxiety, depression, etc.)		   Yes No
  Blood
(cholestral, anemia, lupus, etc.)		   Yes No
 
Past Eye History and Related Systemic Conditions

Have you ever been treated for the following???
  Age Related Macular Degeneration   Yes No
  Glaucoma   Yes No
  Cataracts   Yes No
  Eye Injury   Yes No
  Eye Surgeries   Yes No
  Diabetes   Yes No
  High Blood Pressure   Yes No
  Cancer   Yes No
  Stroke   Yes No
  arthritis   Yes No
  Retinal Disease/Retinal Detachment   Yes No
  Corneal Disease   Yes No
 
Family History 		   
 
Blindness Yes No
Macular Degeneration Yes No
Glaucoma Yes No
Cataracts Yes No
Diabetes Yes No
Cancer Yes No
Other Yes No