MOUNTAINEER VISION CENTER, PLLC

DR. MARK D. ROBINSON

DR. MICHAEL R. LOOPER
827 Fairmont Road, Suites 105-106, Morgantown, WV 26501
Phone: (304) 296-3333 Fax: (304) 296-2220
http://www.mvcpllc.com
PATIENTS NAME: ___________________________________________

DATE: _______________________

MEDICAL HISTORY
DO YOU HAVE ANY OF THE FOLLOWING MEDICAL CONDITIONS?
CONDITION
HYPERTENSION
HEART DISEASE
STROKE
DIABETES
THYROID DISEASE
ARTHRITIS
OSTEOATHRITIS
SINUSITIS
EMPHYSEMA
ASTHMA
KIDNEY DISEASE
HEADACHE
HEAD INJURY
LIVER DISEASE
SEIZURES/TREMORS
LUPUS
ROSACEA
HIGH CHOLESTEROL
CANCER

YES

NO

MEDICATIONS

RHEUMATOID

DO YOU HAVE ANY OF THE FOLLOWING EYE CONDITIONS?

CONDITION

YES

NO

HOW LONG

GLAUCOMA
MACULAR DEGENERATION
CATARACTS
RETINAL DETACHMENT
EYE INJURIES
EYE SURGERIES
BLINDNESS
LAZY EYE

DO ANY OF YOUR FAMILY MEMBERS HAVE ANY OF THESE MEDICAL CONDITIONS?

CONDITION
HYPERTENSION
HEART DISEASE
STROKE
DIABETES
GLAUCOMA
CATARACT
RETINAL DETACHMENT
EYE SURGERIES
BLINDNESS
MACULAR DEGENERATION

YES

NO

WHICH FAMILY MEMBER

DO YOU HAVE DRY EYES?

YES

DO YOU HAVE AIRBORNE ALLERGIES?

NO
YES

ARE YOU ALLERGIC TO ANY MEDICATIONS?

NO

LIST ALL ALLERGY MEDICATIONS BELOW:

YES

NO

IF YES, PLEASE LIST BELOW:

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PLEASE LIST THE REASON(S) FOR YOUR VISIT TODAY:

-------------------------------------------------------------------------------------------------------------------------------------------------------DO YOU WANT (CIRCLE ONE)

GLASSES

ARE YOU PREGNANT?

DO YOU SMOKE?
DO YOU USE BIRTH CONTROL?

YES
YES
YES

CONTACTS

BOTH

NO
NO
NO

PATIENT INFORMATION
FIRST NAME: ___________________________________ MI: ___________ LAST NAME: _____________________________________________
ADDRESS: ___________________________________________________________________________ APT # ____________________________
CITY: _______________________________________________ STATE: ____________________ ZIP CODE: ______________________________
HOME PHONE: ______________________________WORK PHONE: _________________________ CELL PHONE: _________________________
EMAIL ADDRESS: ______________________________________________________________________________________________________
MARITAL STATUS:

SINGLE

GENDER: MALE

FEMALE

MARRIED

LEGALLY SEPARTED

DIVORCED

WIDOWED

DATE OF BIRTH _____________________________________ AGE: __________________________

SOCIAL SECURITY NUMBER: _____________________________________ OCCUPATION: ____________________________________________

EMPLOYER: ___________________________________________________________________________________________________________
FAMILY DOCTOR: ___________________________________________________ FAMILY DOCTOR PHONE # ____________________________
EMERGENCY CONTACT: ___________________________________________________ PHONE #: _____________________________________

INSURED/GUARANTOR INFORMATION (IF NOT SELF OR PATIENT IS A MINOR)

FIRST NAME: ____________________________________ MI: ___________ LAST NAME: ____________________________________________
ADDRESS (IF DIFFERENT THEN PATIENT)
CITY: ___________________________________________ STATE: _______________ ZIP CODE: _______________________________________
HOME PHONE: ______________________________ WORK PHONE: _______________________________ CELL: _________________________
EMPLOYER: ______________________________________________________________ DATE OF BIRTH: _______________________________