Bellflower Optometry

State / Province / Region

Gender:

Female

Male

Other

I stopped wearing glasses
I stopped wearing contact lenses
Headaches
Glare/Light Sensitivity
Tired Eyes
Amblyopia (lazy eye)
Burning
Dryness
Watery Eyes
Eye Pain and/or Soreness
Foreign Body Sensation
Infection of Eye or Lid
Itching

Mucous Discharge
Drooping eyelid(s)
Redness
Sandy or Gritty Feeling
Strabismus (crossed eye)
Blurred Vision at Distance
Blurred Vision at Near
Haloes
Double Vision
Floaters or Spots
Fluctuating Vision
Loss of Vision
Loss of Side Vision

Do You Wear Glassrs:

Yes

Do you wear contact lenses?:

Yes

Chronic fever, unexpected weight loss/gain, fatigue
Ear/nose/throat problems ( eg. Hearing loss, sinus problems, sore throat)
Heart problems (eg. Chest pain, irregular heart beat, swelling of feet, cold hands or feet)
Respiratory problems (eg. Shortness of breath, wheezing, coughing)
Gastrointestinal problems (eg. Heartburn, abdominal pain, diarrhea, vomiting)
Genitourinary problems (eg. Painful urination, blood in urine, sex organ problems)

Musculoskeletal problems (eg. Muscle aches, joint pain, swollen joints)
Skin problems (eg. Rashes, excessive dryness, growths or lumps)
Neurological problems (eg. Numbness, weakness, headaches, “blackouts”)
Psychiatric problems (eg. Depression, anxiety)
Endocrine problems (eg. Frequent urination, thirst, feeling hot or cold all the time)
Blood/Lymph problems (eg. Bruising, weakness, unusual paleness, swollen glands)
mmune problems (eg. Frequent infections, allergic reactions to foods, dust, pollens)

Do you have secondary insurance?:

Yes

Patient Information

Personal Information Information

Gender:

Eye History

Glass History

Do You Wear Glassrs:

Contact Lens History

Do you wear contact lenses?:

Please check off any current conditions you suffer from

Primary Insurance

Please bring all insurance cards with you to your appointment.

Secondary Insurance

Comments

Privacy Policy

Patient Registration Form

Patient Information

Personal Information Information

Gender:

Eye History

Glass History

Do You Wear Glassrs:

Contact Lens History

Do you wear contact lenses?:

Please check off any current conditions you suffer from

Primary Insurance

Please bring all insurance cards with you to your appointment.

Secondary Insurance

Comments

Privacy Policy