don't forget to blink!
PLEASE PRESENT ALL VISION AND MAJOR MEDICAL INFORMATION TO RECEPTIONISTFor Insurance Purposes:
Last Name *
First Name *
Date of Birth *
Last 4 SS# *
Home # *
Vision Insurance :
Primary Language :
Last PCP Visit *
PCP # *
Last Eye Exam *
List any previous surgeries with dates
Are you pregnant?
Are You nursing?
Hobbies/Recreational Sports you enjoy
How many hours per day do you use a computer?
Do you wear glasses?
Do you wear contact lenses? Brand
Are you interested in contact lenses?
Do you perform fine or close-up work?
Do you have trouble reading signs when driving at night?
Are you interested in refractive surgery?
Are you outdoors all or part of the time?
Are you sensitive in bright sunlight?
Are you bothered by glare from:
A computer screen?
Oncoming headlights at night?
Do you currently have or have you ever had, any of the following problems or conditions?
High Blood Pressure
Post Nasal Drip
Ulcer / Reflux
Bladder / Genital / Kidney
Joint / Muscle Pain
Anxiety / Depression
Diabetes Type I
Diabetes Type II
(mark yes or no to each question)
Age-related macular degeneration
Amblyopia (Lazy Eye)
Vision Impaired - one eye
Vision Impaired - both eyes
History of Refractive Surgery
Injury to the eye region
Strabismus (Crossed eyes)
Tear film insufficiency (dry eyes)
Acquired Immune Deficiency Syndrome (AIDS)
Chronic obstructive lung disease (COPD)
Human immunodeficiency virus infection ( HIV)
Hypercholesterolemia (high cholesterol)
Hypertensive disorder (hypertension)
(mark yes or no to each entry. If yes, list which family member including mother, father, brother, sister, maternal/paternal, grandmother or maternal/paternal grandfather)
Amblyopia (Lazy eye)
Blindness and/or vision impairment
Strabismus (cross eyes)
Hypertension (high blood pressure)
(check one for each question)
Do you use recreational Drugs?
Are you a:
(mark which one applies)
List all CURRENT prescriptions, over-the-counter prescriptions, eye drops, and dosages for each.
List any allergies you may have and reactions.
Telephone # *
428 U.S. 206 Bedminster, NJ 07921
At Hills Vision Studio, we provide the highest quality eye care to all our patients. Schedule your appointment today.
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