Patient Information and Medical History Form

Thank you for using our secure online forms. Please fill out as much information as you can. If you have any questions, please call us at (435) 656-2003. We can always change the data in the office if you are unsure about what to enter in any of the fields.
When you are finished be sure to hit the submit button at the bottom of the form.

Patient Information

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

Name
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

Use patient information as billing information
Billing Name
Address
City St  Zip
Hm Phone  
Wk Phone

Vision Insurance

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
This person is NOT the primary policy holder
Policy Holder Information
Name:Last, First, MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical Insurance

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Policy Holder Information
Name:Last, First, MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Policy Holder Information
Name:Last, First, MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Reason for Visit

Reason for Visit
What is the main reason for your visit today?
Secondary Complaints / Symptoms
Please describe any problems you are currently experiencing with your eyes or vision:

Patient Personal General Medical History

We focus on information that helps us care for your eyes and vision.

Primary physician's name or office name  
When was your last physical exam?

Medical History Relevant to Your Eyes & Vision
Please list any medical conditions seen below. Some of these may affect your eyes or vision, even if you don't think they do. This may include conditions such as:
  • Diabetes
  • High blood pressure (hypertension)
  • Autoimmune disease
  • Cancer of any kind
  • Thyroid disease
  • Cancer
  • Neurologic conditions (e.g., migraines, multiple sclerosis)
  • History of steroid use
  • Any other condition you feel may impact your eye health

If none, you may leave this blank.

If you have diabetes, please complete the fields below:

Diabetes
Year Diagnosed
Average Fasting Blood Glucose
Last A1C Level
Pregnancy / Nursing Status
Medications
Please list all medications you currently take
Vitamins & Supplements
Please list any vitamins or supplements you currently take:
Drug Allergies
Please list any medication allergies and your reaction (if known):
Smoking Status Alcohol Use

Family Eye History

Please check any eye conditions that run in your family and indicate who is affected:

Glaucoma
Macular degeneration
Corneal disease
Eye turn / lazy eye / amblyopia
Retinal detachment / retinal disease
Family History Unknown

Ocular History

Please check any eye conditions you have been diagnosed with and provide details if applicable:

Glaucoma
Macular degeneration
Retinal detachment / retinal disease
Cataract
Eye turn / lazy eye / amblyopia

Eye Injuries, Surgeries, or Laser Procedures
Other Eye Conditions or History
Eye Medications
List all prescription or over-the-counter eye drops or treatments you currently use:

Visual Habits & Lifestyle

Digital Device Use
How many hours per day do you spend on computers, phones, or tablets?
Computer Distance (if applicable)
If you use a computer regularly, how far is the screen from your eyes?
Near Work / Reading
How many hours per day do you spend reading or doing close work?
Hobbies & Activities
What activities or hobbies are important to your vision? (sports, driving, crafts, etc.)

Glasses & Contact Lens Use

Sunglasses
Do you currently have prescription or non-prescription sunglasses?
Back-up Glasses
Do you have a spare pair of glasses?
Contact Lens Status
Do you currently wear contact lenses?

Contact Lens Details (if applicable)

Contact Lens Cleaning Solution Used
Daily Wear Time
How many hours per day do you wear your contact lenses?
Replacement Schedule
How often do you replace your contact lenses?
Age of Current Lenses
How long have you been using your current contact lenses?

Acknowledgements

By checking below, you acknowledge that:

  • You have reviewed our Notice of Privacy Practices
  • You consent to evaluation and treatment
  • You understand you are responsible for charges not covered by insurance

I acknowledge and agree to the above
Electronic Signature
Date

You're Done! Please hit the Submit button below.