MedicalHistoryForm

Medical History Form

Welcome to our office. Please fill out this form as thoroughly as possible. A save button is located at the bottom of the form in the event that you need to continue at a later time.
Full Name *

First Name Middle Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of Birth *

Month Day Year
Date
Age *
Gender *
Last Four Digits of Social Security Number (SSN) *
*SSN will be used for gathering insurance information prior to your appointment
Email *
example@example.com
Cell Phone Number *

Area Code Phone Number
Occupation and Employer
If student: Grade level
How did you hear about our office?

VSP List Internet Walk In Yelp Referred
Reason for eye exam?

Blurry Vision Distance Blurry Vision Near Routine Eye Exam Broken Glasses Scratched Glasses Lost Glasses Other Vision problem
Medical Insurance Name

Kaiser Blue Cross PPO Blue Shield Aetna
Does your company offer a Flexible Spending Plan (FSA)?
Do you participate in the FSA Program?
Does your company offer a Flexible Spending Account (FSA), Health Savings Account (HSA) or Health Reimbursement Account (HRA)?

Yes No Do not know
Do you participate in the FSA or HSA Program?

Yes No
Date of Last Eye Exam *

Month Day Year
Years of Current Glasses/Contacts
Name of Previous Optometrist or Ophthalmologist. In what city?
Date of Last Physical

Month Day Year
Date
Physician's Name
Location of Medical Care

Kaiser Seton
Check the conditions that apply to you or family members: *

Diabetes Hypertension / High blood pressure Cholesterol Thyroid Asthma Heart Problems Anxiety Depression None / Not Sure Acid Reflux
Check the eye conditions/diseases that apply to you or to any members of your immediate relatives: *

Glaucoma Macular Degeneration Cataracts Eye turn / Lazy Eye Dry / Watery Eyes Retinal Detatchment None / Not Sure Blindness
Are you currently taking any medication? *

Yes No
Please List Medications and Dosages
Do you have any allergies to food, medication or metals? *
Seasonal Allergy (Pollen) Metals / Nickle Penicillins Sulfa
Please list any additional allergies:
Have you ever had any infection / disease / injury / surgery of the eye? *
Please list any infections, diseases, or injuries of the eye and which eye:
Please list any previous or future eye surgeries and which eye:
Do you notice floaters, flashes of light or double vision? *
Since when and which eye?
Do you experience regular headaches? *

Do you get motion sickness or fall asleep when reading? *
Are you or have you ever been a smoker of cigarettes / alcohol / substance abuser? *
If so which?

Cigarettes Alcohol Marijuana / Cannabis Illegal Substances
Have you or any immediate family members had cancer? *
Do you experience eye strain or fatigue on a computer? *
Do you have separate computer glasses? *
Do you have or wear prescription sun glasses?

Yes No
Do you currently wear contact lenses? *
Contact lens type?
Type and brand of Contact Lens worn?

Daily / Single Use Two Week Montly
Are you interested in contacts lenses? *
Do any immediate family members wear glasses or contacts? *
If so who?

Me Mother Sibling Daughter Father Son
Feel free to attach any photos/videos related to external eye problems:

Browse Files

Cancel of
Anything you would like Lum Optometry to be aware of before your appointment:
Should be Empty:

Medical History Form