Patient Information and Medical History Form

Thank you for using our secure online forms. Please fill out as much information as you can. When you are finished be sure to hit the submit button at the bottom of the form. If you have any questions, please call us at (281) 648-1910. We can always change the data in the office if you are unsure about what to enter in any of the fields.

Patient Information

*required (first and last name and either a home OR cell phone)

Title	First*	Last*	MI	Suffix	Nickname

Address

City	St	Zip

Hm Phone*
Cell Phone*
Wk Phone
Other Phone
Email
Preferred Contact By
DOB (mm/dd/yyyy)
Sex	Female Male
Marital Status
Employment Status	Employed FT Student PT Student
Occupation/Grade
Employer/School
Parent/Guardian
Race
Ethnicity
Preferred Language

Who may we thank for referring you to our office?

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix

Address

City	St	Zip
Hm Phone
Wk Phone

General Medical History

Primary physician's name and phone
When was your last physical exam?

Check the box for any conditions that apply:

	You	Mom	Dad	Sib	Describe (type, when were you diagnosed, etc)
Hypertension
Thyroid
Cardiovascular
Cancer
Diabetes

If *YOU* are diabetic, when were you diagnosed?		Last A1C level?
Are you Pregnant or Nursing?

List ALL major injuries or surgeries you have had and approx dates:

List any other medical conditions you have had, including non-drug allergies:

List all Rx and over-the-counter medications you currently take:

List any vitamins or supplements you currently take:

List any drug allergies you have:

Smoking Status
Alcohol Use
Do you live alone?

Review of Systems

Please describe any health problems you have been diagnosed with or treated for:

General (e.g., fever, fatigue, loss of appetite, unexplained weight loss/gain)

Ear, Nose, Throat (e.g., sinus/nasal congestion, nose bleeds, dry mouth/throat, sleep apnea, hearing problems)

Cardiovascular (e.g., chest pain, racing heartbeat, swollen feet/ankles, TIAs)

Respiratory (e.g., chronic cough, shortness of breath, wheezing)

Genital, Kidney, Bladder (e.g., bladder/urinary problems, pain, discharge, menstrual changes, impotence)

Gastrointestinal (e.g., constipation, diarrhea, gastric reflux (GERD), jaundice, nausea, vomiting)

Endocrine (e.g., heat or cold intolerance, thinning hair, excess thirst, excess urination)

Muscles, Bones, Joints (e.g., pain, stiffness, swelling, weakness, limited movements)

Skin (e.g., dry, itchy, flaky, rash, growths, bumps, redness, discoloration)

Neurological (e.g., headaches, numbness/tingling, tremors, poor balance, dementia, speech problems)

Psychiatric (e.g., depression, anxiety, sleep problems, paranoia, obsessive/compulsive)

Blood/Lymph (e.g., anemia, bleeding gums, delayed clotting, unexplained bruising)

Allergy/Immune (e.g., swollen lymph nodes, itching, sneezing, runny nose/eyes)

Ocular History

Who was your previous eye doctor?
When was your last eye exam?

Do you currently or have previously worn prescription glasses?

Yes No

Do you currently wear or have a prescription for contact lenses?

Yes No

List any vision or eye health complaints you are currently having such as:

blurred vision, headaches, eyestrain, double vision, or losing your place when reading
itching, burning, redness, pain, sensitivity to light, watering, crusting or mucus discharge
seeing rainbows around white lights at night, flashes of light or dark spots/squiggles/webs

Check the box for any conditions that apply:

	You	Mom	Dad	Sib	Describe (type, when diagnosed, which eye(s), treatment,etc)
Glaucoma
Macular Degeneration
Retinal problems
Cataracts
Lazy Eye/Eye Turn

List any major eye injuries, infections or surgeries and approx dates:

List any other significant eye problems you have had:

List all Rx and over-the-counter eye medications you currently use:

What are your hobbies?

How many hours per day do you typically spend on digital devices?
How many hours per day do you spend outdoors?
How often do you wear your sunglasses?
Are you interested in being fit for or receiving a prescription for contact lenses?
Glasses Wearers
How ofen do you wear your glasses?
What kind of prescription glasses do you wear? For example, over the counter readers, progressives, for driving, etc?
How old is your current pair of prescription glasses?
Contact Lens Wearers Only
How often do you wear your contacts?
How many hours per day are you able to comfortably wear your current contacts?
What brand of contact lenses are you currently wearing?
How frequently do you replace your lenses?
Do you have a current pair of glasses for when you are not wearing contacts?

Patient Information and Medical History Form