Patient Information and Medical History Form

Thank you for using our secure online form. Please fill out as much information as you can. Once you have completed this comprehensive form, you will only need to report changes for future visits. When you are finished, be sure to print a copy for your records before selecting the submit button at the bottom of the form. If you have any questions, please call RedWood Eye Clinic at (425) 483-8000, or Bothell VIsion Center at (425) 486-2121. 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)

City  State   Zip 
Hm Phone*
Cell Phone*
Wk Phone
Other Phone
Preferred Contact By
DOB (mm/dd/yyyy)  
Sex Female Male
Marital Status
Employment Status Employed FT Student PT Student
Preferred Language

Who may we thank for referring you to our office?


Billing Information

Is The Billing Address the Same?

City  State   Zip
Hm Phone 
Wk Phone


Primary Medical Insurance

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

Vision Insurance

Insurance Information
Insurance Name:
Insurance ID:


General Medical History

Primary physician's name, phone and fax number  
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)
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. Type "none" if applicable.
List any other medical conditions you have had, including non-drug allergies. Type "none" if applicable.
List all Rx and over-the-counter medications you currently take. Type "none" if applicable.
List any vitamins or supplements you currently take. Type "none" if applicable.
List any drug allergies you have. Type "none" if applicable.
Smoking Status
Alcohol Use
Do you live alone?  


Review of Systems

Please list any issues you are currently experiencing. Type "none" (lowercase) where applicable.

General (e.g., fever, fatigue, night sweats, loss of appetite, unexplained weight loss/gain)
Ear, Nose, Throat (e.g., sinus/nasal congestion, nose bleeds, dry mouth/throat, snore, hearing problems)
Cardiovascular (e.g., chest pressure or discomfort, irregular heartbeat)
Respiratory (e.g., cough, shortness of breath, wheezing)
Genital, Kidney, Bladder (e.g., bladder/urinary problems, ED, pain, discharge, menstrual changes)
Gastrointestinal (e.g., constipation, diarrhea, acid reflux, jaundice, nausea, vomiting)
Endocrine (e.g., heat or cold intolerance, thinning hair, excess thirst, excess urination, constant hunger)
Muscles, Bones, Joints (e.g., joint pain, stiffness, swelling, muscle weakness)
Skin (e.g., rash)
Neurological (e.g., headaches, numbness/tingling, tremors, dizziness, balance, memory, speech issues)
Psychiatric (e.g., emotional changes, depression, anxiety, ADHD, sleep problems, paranoia, obsessive/compulsive)
Blood/Lymph (e.g., bruising, easy bleeding)
Allergy/Immune (e.g., environmental allergies, food allergies)


Ocular History

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

Check the box for any conditions that apply:

You Mom Dad Sib Describe (type, when diagnosed, which eye(s), treatment,etc)
Macular Degeneration
Retinal problems
Lazy Eye/Eye Turn
List any major eye injuries, infections or surgeries and approx dates. Type "none" if applicable.
List any other significant or chronic eye problems you have or had. Type "none" if applicable.
List all Rx and over-the-counter eye medications you currently use. Type "none" if applicable.
What is your main concern or reason for your visit, for example:
  • 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
How many hours/day do you typically spend using a computer or other digital devices?
Exactly how far (in inches) is your computer monitor from your eyes? 
How many hours per day do you typically spend reading books, magazines, etc?
What are your hobbies/sports activities?
Do you have sunglasses?
Do you have back-up glasses?
Are you interested in contacts?
Contact Lens Wearers Only:
What contact lens solution do you currently use?
How many hours do you wear your lenses each day?
How often do you replace your lenses?
How old is your current pair of contacts?

Unless a pupil dilation is ordered by the doctor, an ultra-wide retinal scan is the quickest, most comfortable way of evaluating the health of your retina in great detail without the need for pupil-dilating eyedrops. Recommended for age 5 and older, the retinal scan is fast, safe, and painless, and will not induce the four hours of blurred vision and light sensitivity that you would normally experience after having your eyes dilated. Your insurance plan may cover the retinal scan with or without a copay; without coverage, the retinal scan is $45.00. Please check the box if you would like to request the retinal scan at your upcoming visit:

Retinal Scan Requested YES


All finished!

By clicking the Submit button below, I attest that the information I have provided on this form is complete, true, and accurate to the best of my knowledge. I understand that neither the doctors nor clinic staff can guarantee my insurance eligibility or coverage, and that I am financially responsible for all charges, whether or not paid by my insurance, with my estimated portion due at the time of service. *I further attest that I have not had any symptoms of, nor tested positive for, the COVID-19 virus within the last 14 days and agree to notify the clinic immediately should my status change before, or within 10 days after, my appointment.