Patient Health History Form

Patient Health History Form

Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.
*Asterisk denotes required field

Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.

This form contains confidential information and is delivered to your doctor through a secure Internet connection.
Patient Information
Full Name *
Address*
Phone Number*
Daytime Phone
Cell Phone
Email Address
Personal Information
Gender*

FemaleMale
Date of Birth*

MonthDayYear
Social Security Number (last 4 digits only!)
Please enter a value between 0000 and 9999.
Preferred Language*
Race *
Ethnicity*
Marital Status
Employment Status
Employer
Occupation
How were you referred to our office?
Communication Preference
Eye History
Please check off any current conditions you suffer from*

I stopped wearing glassesI stopped wearing contact lensesHeadachesGlare/Light SensitivityTired EyesAmblyopia (lazy eye)BurningDrynessWatery EyesEye Pain and/or SorenessForeign Body SensationInfection of Eye or LidItchingMucous DischargeDrooping eyelid(s)RednessSandy or Gritty FeelingStrabismus (crossed eye)Blurred Vision at DistanceBlurred Vision at NearHaloesDouble VisionFloaters or SpotsFluctuating VisionLoss of VisionLoss of Side Vision
Glasses History
Do you wear glasses?*

YesNo
Contact Lens History
Do you wear contact lenses?*

YesNo
Medical History
When, approximately, was your last eye exam?
Where did you get your last eye exam?
When, approximately, was your last physical exam?
Who is your primary care physician?
Who is your primary care physician?
Do you drink alcohol?
Do you smoke?
Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)
Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)
Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)
Please list all hospital surgeries you have ever had:
Please list all prescription and over-the-counter medications you take and for what conditions
Please list all drug allergies you have
lease check off any current conditions you suffer from

Chronic fever, unexpected weight loss/gain, fatigueEar/nose/throat problems ( eg. Hearing loss, sinus problems, sore throat)Heart problems (eg. Chest pain, irregular heart beat, swelling of feet, cold hands or feet)Respiratory problems (eg. Shortness of breath, wheezing, coughing)Gastrointestinal problems (eg. Heartburn, abdominal pain, diarrhea, vomiting)Genitourinary problems (eg. Painful urination, blood in urine, sex organ problems)Musculoskeletal problems (eg. Muscle aches, joint pain, swollen joints)Skin problems (eg. Rashes, excessive dryness, growths or lumps)Neurological problems (eg. Numbness, weakness, headaches, “blackouts”)Psychiatric problems (eg. Depression, anxiety)Endocrine problems (eg. Frequent urination, thirst, feeling hot or cold all the time)Blood/Lymph problems (eg. Bruising, weakness, unusual paleness, swollen glands)Immune problems (eg. Frequent infections, allergic reactions to foods, dust, pollens)
Primary Insurance

Please bring all insurance cards with you to your appointment.
Insurance Company Name
Insurance Company Phone Number
Address
Insured's Name
Group Number
Date of Birth

MonthDayYear
Patient's Relation to Insured
Secondary Insurance
Do you have secondary insurance?

YesNo
Comments
If you have any comments you would like to add, please enter them here.
Privacy Policy
Health Information Protection *

I have read and agree to the Privacy Policy *
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Patient Health History Form

Patient Information

Personal Information

Eye History

Glasses History

Contact Lens History

Medical History

Primary Insurance

Secondary Insurance

Comments

Privacy Policy