The Focal Pointe... Tallahassee's premier provider of eyewear and Optometric services since 1976. The Focal Pointe's mission is to provide the finest in full service eye care.

The Focal Pointe
2724 Capital Circle NE Suite 1
Tallahassee, FL 30308
850-385-4444
eyesite@nettally.com

Personal Information:

Dr. Mr. Mrs. Ms. Miss

First Name:
Last Name:
Street:
City:
State:
Zip:
E-Mail:
Home Phone:
Work Phone:
Birthdate:
Social Security #:
Marital Status:

Other family members who are patients at The Focal Pointe

Responsible Party: Relationship:
Comments:
(e.g., address, if different from patient's)

Insurance Information:

Primary Insurer:
Vista BCBS CHP United Medicare
None Other
(Note: Some health plans have vision coverage included in their benefits.)

Primary Insurance ID#: (example: XJU123-45-7889)

Secondary Insurer:

(e.g., Medicare Supplements)

Secondary Insurance ID#:

Eye History:

When was your last eye exam?

Major Illness / Injuries	Surgeries	Current Medications

Drug Allergies?

Do you currently experience:

Headaches	Y N
Drooping Lid (Ptosis)	Y N
Glare/Light Sensitivity	Y N
Redness	Y N
Tired Eyes	Y N
Sandy or Gritty Feeling	Y N
Crossed Eyes (Strabismus)	Y N
Amblyopia	Y N
Burning	Y N
Blurred Distance Vision	Y N
Dryness	Y N
Blurred Near Vision	Y N
Excess Watering (Epiphora)	Y N
Distorted Vision or Haloes	Y N
Eye Pain or Soreness	Y N
Double Vision	Y N
Foreign Body Sensation	Y N
Floaters or Spots	Y N
Infection of Eye or Lid	Y N
Loss of Vision	Y N
Itching	Y N
Loss of Peripheral Vision	Y N
Mucous Discharge	Y N

Review Of Symptoms:

Have you ever had problems with:

High Fever	Y N
Muscle, Bones, Joints	Y N
Weight Loss	Y N
Skin (Acne, Cancer, etc.)	Y N
Ear, Nose, Sinus, Throat	Y N
Nerves (Numbness, etc.)	Y N
Heart / Blood Vessels	Y N
Psychiatric (Anxiety, Depression)	Y N
Breathing (Asthma, Emphysema)	Y N
Diabetes or Thyroid	Y N
Stomach / Bowel	Y N
Blood / Lymph	Y N
Genital, Kidney, Bladder	Y N
Allergic / Immunologic (Hayfever, Lupus)	Y N

Family History

Have any family members ever had trouble with:

Lazy Eye / Amblyopia	Y N
Arthritis	Y N
Blindness	Y N
Cancer	Y N
Cataracts	Y N
Diabetes	Y N
Color Blindness	Y N
Heart disease	Y N
Glaucoma	Y N
High Blood Pressure	Y N
Macular Degeneration	Y N
Kidney Disease	Y N
Retinal Detachment	Y N
Lupus	Y N
Crossed Eyes (Strabismus)	Y N
Stroke	Y N
Thyroid Disease	Y N

Habits:

Employer:
Occupation: If Other:

Computer used at work or home? Y N
If so, how many hours per day?

Do you drive? Y N
If so, do you have visual difficulty when driving? Y N

Do you have problems with night vision? Y N

Does glare bother you? Y N

Have you ever worn Contact Lenses? Y N
Reason for stopping:

Do you currently wear contact lenses? Y N
How long?

Do you currently wear glasses? Y N
Full Time Part Time

Glasses Owned:

Single Vision	Bifocals
Progressives	Sports Glasses
Computer Glasses	Hobby Glasses
Non-prescription Glasses	Prescription Sunglasses
Trifocals	Safety Glasses

Do you drink alcohol?
No Occasionally 1 per day 2-3 per day 4+ per day

Do you smoke?
No Occasionally 1/2 pk/day 1 pk/day Over 1pk/day

Ethnicity

Additional Comments / Concerns: