First Eye Care
Phil Stiles, O.D.
2810 E. Trinity Mills Rd #173
Alan Weissman, O.D.
Carrollton TX 75006
Chris Peterson, O.D.
972-416-1270
Melinda Surdacki, O.D.
PATIENT INFORMATION
Nickname
Zip

How did you hear about us? (friend, family, insurance, internet, etc.)

Please note any conditions or problems you are having with your EYES.
Blurred distance vision
 
Glaucoma
Blurred near vision
 
Cataracts
Redness
 
Macular degeneration
Burning
 
Glare/light sensitivity
Tearing
 
Floaters/flashers
Itching
 
Double vision
Dryness
 
Eye surgery
Pain
 
Eye injury
Additional information

Do you wear glasses?
Do you wear contacts?

Please note any conditions or problems you are having with your general HEALTH.
Headaches
Cholesterol
Migraines
Diabetes
Allergies/hayfever
High blood pressure
Asthma
Rheumatoid arthritis
List the medications you are taking:
Other conditions or problems:

Are you allergic to any medication? If yes, please list:
Please note any family history for the following conditions. Family would include: parents, grandparents, siblings and children.
FAMILY history of EYE conditions
Lazy Eye/ Amblyopia
Glaucoma
Macular Degeneration
Retinal Detachment/Disease
Additional information: