World Eyeglasses & Personal EyeCare

www.WorldEyeGlasses.com

6201 N. Federal Hwy, Fort Lauderdale, Florida 33308 (ON FEDERAL HWY. Between Commercial & Atlantic Blvd.- In SAME Plaza as OUTBACK & SUBWAY)

About Dr. Gary Enker
Owner & Board Certified Optometrist

World Eyeglasses & Personal Eyecare
www.WorldEyeGlasses.com
Serving Fort Lauderdale, Florida Since 1991!

6201 N. Federal Hwy Fort Lauderdale,
33308 (ON Federal Hwy Between Commercial & Atlantic Blvd.- In Same Plaza as OUTBACK & SUBWAY)
954-491-7141

Visit AllAboutVision.com for guides to glasses and contacts, and to learn about eye health topics such as cataracts and glaucoma

Not sure what to do? Please follow the instructions on this page.

You may Also Print & Fax ( Fax #: 954-491-7164 )

Medical History

PATIENT MED-HISTORY

Select Doctor

Patient Status

First Name

Last Name

Birth of Date

Address

City

State

Zip

Tel

Cell

SS #

Gender

Marrital Status

Last Exam

Exam Type Wanted

Do you currently wear:

Glasses Type

Yes
No

Contact Lences

Contact Lenses

Yes
No

Lower Vision Aids Type

Lower Vision Aids

Yes
No

Do you currently have or have you ever had any of the following:

Eye Surgeries

Yes
No

Eye Injuries

Yes
No

Eye Infections

Yes
No

Amblyopia

Yes
No

Cataracts

Yes
No

Dry Eyes

Yes
No

Light Sensitivity

Yes
No

Pain

Yes
No

Glaucoma

Yes
No

Lazy Eye

Yes
No

Macular Degeneration

Yes
No

Eye Turn In / Out

Yes
No

Reading Problems

Yes
No

Tracking Problems

Yes
No

Other

Yes
No

Do you Have:

Diabetes

Yes
No

High Blood Pressure

Yes
No

Headaches

Yes
No

Medication - List any Medications:

Are you currently taking prescription or non-prescription drugs?

Yes/No

Yes
No

Allergies - List any known Allergies:

Do you currently have any Allergies known or perceived?

Yes/No

Yes
No

Do you have problems with any of these systems? - Please check all that apply

Allergic / Immunologic

Yes
No

Arthritis

Yes
No

Blood / Lymph

Yes
No

Cardiovascular Heart Disease

Yes
No

Ear / Nose / Throat

Yes
No

Endocrine Glands

Yes
No

Gastrointestinal

Yes
No

Integument Skin

Yes
No

Kidney Problems

Yes
No

Musculature

Yes
No

Nervous

Yes
No

Psychiatric

Yes
No

Respiratory

Yes
No

Skeletal Bones

Yes
No

Thyroid Problems

Yes
No

Other (explain bottom of page)

Yes
No

Do you use - Please select all that apply

Cigarettes?

Yes
No

Alcohol?

Yes
No

Other substances?

Yes
No

Family Eye History - Anyone in patient's family (blood relative) had any of the following?

Cataracts

Yes
No

Cornea Disease

Yes
No

Diabetes

Yes
No

Glaucoma

Yes
No

Lazy Eye

Yes
No

Macular Degeneration

Yes
No

Retina Disease

Yes
No

High Blood Pressure

Yes
No

Other Eye Disorders

Yes
No

Your Surgical History- List any type of surgery and dates of surgery

Your Surgical History

Occupation- If applicable, what type of work do you do?

Occupation

Hobbies- List any hobbies or sports you participate in

Hobbies

Vision Correction Preferences, Interests- Put a check in any boxes that interests you

LASER VISION CORRECTION

Laser Vision Correction
LASIK With The New Wavefront® Technology

CONTACT 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
No Charges For One Year For CL Solutions, Replacement Or Power Changes, & One Office Visit

EYEGLASSES

Extra Thin And Light Eyeglass Lenses
Crizal Anti-Reflective (Glare-Free) Lenses. Reduce Eyestrain. Great For Night Vision & Computers
Designer Frames - Armani, Calvin Klein, Marchon, Prada-(Exclusive To Our Office), Etc.
Frames That Weigh Less Than A Feather - Airlocks, Silhouette, Etc.
Invisible Bifocal (No-Line Progressives) - Varilux, Seiko, Zeiss, Sola, Etc.
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.
Discount For Second Pair

SUNGLASSES

UV (Ultra-Violet) Light Protection
Polaroid Lenses -Considerably Reduces Sun & Reflective Glare, & Eliminates Horizontal Reflections
Sunglasses To Wear With Contact Lenses
Discount For Second Pair

CHILDREN'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

MISCELLANEOUS

$25 Gift Certificate And Information On How To Get $25 Off Your Next Purchase As Well

Other Information- Please elaborate on any information or from any "Other" box above.

Other Information

Joomla Professional Work