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 NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
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 CodePhone Number
Occupation and Employer
If student: Grade level
How did you hear about our office?

VSP ListGoogleYelpInternetWalk InReferred
Reason for eye exam?

Blurry Vision DistanceBlurry Vision NearRoutine Eye ExamBroken GlassesScratched GlassesLost GlassesOther Vision problem
Medical Insurance Name

KaiserBlue CrossPPOBlue ShieldAetna
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) or Medical Reinbursment Account (MRA)?

FSAHSAMRADon't Know.
Do you currently participate in the FSA, HSA or MRA Program?

YesNo
Date of Last Eye Exam*

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

MonthDayYear
Date
Physician's Name
Location of Medical Care

KaiserSetonSutter
Check the conditions that apply to YOU:*

DiabetesHypertension / High blood pressureCholesterolThyroidAsthmaHeart ProblemsAnxietyDepressionNone / Not SureAcid Reflux
Check the eye conditions/diseases that apply to YOU:*

GlaucomaMacular DegenerationCataractsEye turn / Lazy EyeDry / Watery EyesRetinal DetatchmentNone / Not SureBlindness
Check the conditions that apply FAMILY members:*

DiabetesHypertension / High blood pressureCholesterolThyroidAsthmaHeart ProblemsAnxietyDepressionNone / Not SureAcid Reflux
Check the eye conditions/diseases that apply to any FAMILY members:*

GlaucomaMacular DegenerationCataractsEye turn / Lazy EyeDry / Watery EyesRetinal DetatchmentNone / Not SureBlindness
Are you currently taking any medication?*

YesNo
Please List Medications and Dosages
Do you have any allergies to food, medication or metals?*
Seasonal Allergy (Pollen)Metals / NicklePenicillinsSulfa
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, which eye and date of occurance:
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 sicknes, fall asleep when reading or get dizzy at 3D movies?*
Are you or have you ever been a smoker of cigarettes / alcohol / substance abuser? *
If so which?

CigarettesAlcoholMarijuana / CannabisIllegal 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?

YesNo
Do you currently wear contact lenses?*
Contact lens type?
Type and brand of Contact Lens worn?

Daily / Single UseTwo WeekMonthlyAcuvueCIBACooperBausch and Lomb
Are you interested in contacts lenses? *
Do any immediate family members wear glasses or contacts?*
If so who?

MeMotherSiblingDaughterFatherSon
Feel free to attach any photos/videos related to external eye problems:

Browse Files

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

Medical History Form