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 650-593-1661. We can always change the data in the office if you are unsure about what to enter in any of the fields.

Please read and sign the financial policy at the bottom of the page before submitting your form. Thank you!

When you have finished filling out your information, please click the Submit button below.


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

TitleFirst*Last*MISuffixNickname
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?

TitleFirstLastMISuffix
Address
City St  Zip
Hm Phone  
Wk Phone

Vision Service Plan

We are providers for VSP and Medicare. If you have Medicare, please bring your card.

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
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:



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FINANCIAL POLICY, RELEASE OF INFORMATION, AND ASSIGNMENT OF BENEFITS

Optometric Center for Family Vision Care and Vision Therapy extends the courtesy of filing to your insurance company.
However, insurance coverage is a contract between you and your insurance company, and you are ultimately responsible for the payment of services rendered.

I agree that all co-payments and/or deductible amounts due will be paid at the time services are rendered, unless payment arrangements have been made. I authorize payment of medical benefits directly to Family Vision Care and Vision Therapy for services rendered and allow the release of any information necessary to obtain payment.


Patient, Parent or Guardian Electronic Signature (Please type name)
Date:


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After this point, please fill out ONE section only. If you need to fill multiple forms, please submit the first before beginning the next.

Please click the age of the patient to go to the correct form.
   0-4   5-17   18+

Patients 18+

General Medical History

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

Check the box for any conditions that apply:

You Family None Describe (type, when were you diagnosed, etc)
Hypertension
Thyroid
Cardiovascular
Cancer
Diabetes
Cholesterol
If YOU are diabetic, when were you diagnosed?    Last A1C level? 
Fasting Blood Sugar:
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 list any problems you are currently having anywhere, from head to toe:

(No For All Below)

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?

Check the box for any conditions that apply:

You Family None Describe (type, when diagnosed, which eye(s), treatment,etc)
Glaucoma
Macular Degeneration
Retinal problems
Cataracts
Lazy Eye/Eye Turn

Have you ever been diagnosed or treated for:
Corneal Abrasion             Iritis/Uveitis
Eye Infection             Eye Injury
Other Eye Disorder

If yes, please explain:



Ocular Symptoms:

Do you currently use:
Glasses Contact Lenses No Correction

Do you ever experience (check all that apply):
Far Vision Blur Sunlight Sensitivity Burning/Dryness/Tearing Rubs Eyes Excessively
Itchiness Headaches Poor Night Vision Discomfort w/Glasses/Contacts
Errors While Copying Poor Reading Comprehension Night Vision Blur Floaters/Spots
Red Eyes Often Crossed Eye/Eye turn Double Vision Eye Strain/Fatigue
Flashes of Light Loss of Place While Reading Car Sickness

If yes, please explain:
List all Rx and over-the-counter eye medications you currently use:

Please select all that apply:
Interested in trying latest contact lenses?
Interested in non-surgical approach to vision correction?
Want information on Laser Vision Correction surgery?
Interested in prescription sunglasses?
Have more than one current prescription for glasses?
Want thinner, light glasses?
Experience symptoms during or after use of computer/tablet/phone use?
Want to improve reading comprehension or sports performance?
Need sports goggles or safety glasses?
Have family in need of eye care?

Have children? Please list names and ages:


Contact Lens Wearers Only - Please bring boxes or top of contact lens packages with you to exam.
What disinfecting solution do you use?
How long do you usually wear your lenses?
How often do you replace your lenses?
How old is your current pair of contacts?
Are your contacts uncomfortable just before you take them out at the end of the day?
Do you use contact lens rewetting drops?


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Patients 5-17 (Grades k-12)

General Medical History

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

Check the box for any conditions that apply:

None Child Maternal Paternal Sib Describe (type, when was your child diagnosed, etc)
Hypertension
Thyroid
Cardiovascular
Cancer
Diabetes
Cholesterol
If YOUR CHILD is diabetic, when were they diagnosed?    Last A1C level? 
Fasting Blood Sugar:
List ALL major injuries or surgeries your child has had and approx dates:
List any other medical conditions your child has had, including non-drug allergies:
List all Rx and over-the-counter medications your child currently takes:
List any vitamins or supplements your child currently takes:
List any drug allergies your child has:

Review of Systems

Please list any problems your child currently has anywhere, from head to toe:

(No For All Below)

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 child's previous eye doctor?  
When was your child's last eye exam?

Check the box for any conditions that apply:

None Child Maternal Paternal Sib Describe (type, when diagnosed, which eye(s), treatment,etc)
Glaucoma
Macular Degeneration
Retinal problems
Cataracts
Lazy Eye/Eye Turn

Has your child ever been diagnosed or treated for:
Corneal Abrasion             Iritis/Uveitis
Eye Infection             Eye Injury
Other Eye Disorder

If yes, please explain:



Contact Lens Wearers Only - Please bring boxes or top of contact lens packages with you to exam.
What disinfecting solution does your child use?
How long does your child usually wear their lenses?
How often does your child replace their lenses?
How old is your child's current pair of contacts?
Are your child's contacts uncomfortable just before they take them out at the end of the day?
Does your child use contact lens rewetting drops?


What is the major reason for this visual evaluation?:
Periodic check-up            School Referral
Visual Symptoms            Learning Problem
Doctor Referral            Other  

Please state your main concerns:

Have the following vision treatments ever been prescribed or recommended? If yes, at what age?
Glasses: Patching: Surgery:

Visual HistoryYes  No  Unknown
Headaches:          
Blurred Distance Vision:          
Blurred Near Vision:          
Hold books closer than normal:          
Eyes hurt or tire:           
Eyes frequently red:          
Double vision or closes one eye:          
Eye turn (crossed or wall-eyed):          
Rubs or blinks excessively:          
Makes erros when copying:          
Loses place while reading:          
Poor reading comprehension:          
Suffers from carsickness:          
Have previous visual
problems been diagnosed?:		          

Academic History

Yes  No
Are you dissatisfied with your child's school performance?  
Do teachers have concerns about his/her school performance?  
Has a grade level been repeated?  

Rate progress in the following subjects:
1 - below average, 2 - average, 3 - advanced

Reading: Spelling: Penmanship: Math: Writing: Physical Ed:

Behavioral History: Please check the items that describe the child.
Hyperactive    Poor ability to organize work
Easily distracted    Indistinct Speech
Short attention span    Trouble with Verbal Instructions
Easily frustrated    Poor Peer Group Relations
Impulsive    Behavior Problems
Easily fatigued    Emotional Problems
Day dreams    Does little voluntary reading
Confuses right and left    Reverses letters when reading or writing
Awkward or clumsy    Confuses letters or words when reading
Rejects eye-hand activities    Variable school performance (hour-to-hour, day-to-day)

Developmental and Medical History:

At what age, in months, did the child:
   Crawl:    Walk:    Speak Clearly:

Which describes the child's physical maturity for age?:
  Immature  Average  Advanced

Any history of birth complications?

Any severe childhood illness, high fever,
ear infections, injury, or physical impairment?

Any allergies?

Are herbal, over-the-counter, or prescribed
medications taken? If yes, list and state their purpose.

Has hearing, auditory processing, or speech deficiency been diagnosed?

Any previous testing, therapy, or remedial assistance?
(Type, Dates, By Who, Results)

Any unusual sensitivities to clothing,
crowded places, tastes, loud sounds, or odors?

Any family history of these conditions, and if so, whom?:
   Glaucoma:    Color Deficiency:
   Cataracts:    Lazy Eye or Eye Turn:
   High Blood Pressure:    Blindness Due to:
   Diabetes:    Learning Difference:


Is there any other information that you feel
would be helpful/important for the doctor to know?


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Infants and Pre-school (ages 0-4)

Eye History

Explain any eye concerns noted by observing child:

Have you ever noticed any of the following happening with your child's eyes? (Please check any that apply)
  Eye Turn: In Out
   Eyes Watering Eyes Red Swelling around the eyes White appearance in pupil

Have the following vision treatments ever been prescribed or recommended? If yes, at what age?
   Glasses: Patching: Vision Therapy: Surgery:

Developmental and Health History

Pregnancy History
Unsure of Pregnancy Hx Adopted

Length of pregnancy: weeks         List any complications during pregnancy:
Type of delivery:

Other pregnancy issues:

Delivery
Birth Weight:         Parents ages at time of birth: Mother Father

List any complications during delivery:

Was oxygen used?:NoYes      APGAR score at birth (if known):

Medical
Child's Doctor:    Last Exam Date:    Are immunizations up to date?Yes No

Does your child have any known food or drug allergies?:   Yes: No

List ALL medications taken regularly:   List: None


Developmental Milestones
Please check any delays or concerns in any of these areas:
Sit Without Support   Hand Grasp   Rides Tricycle
Crawl On Hands/Knees   Scribbles Spont.   Knows Colors
Walks Unaided   Combines Words   Fine Motor Control
Head Control   Copies Circles   Attention

Has your child ever had a high temperature (fever)?:   Yes, how high? No

Does your child have a history of ear infections?: Yes No

Illness:    Age at the time:   Severity:Mild Moderate Severe
Illness:    Age at the time:   Severity:Mild Moderate Severe

List any accidents, eye, or head injuries, and age they occurred:     Please list any other conditions we should know about:
    

Family History

Do any family members have:
    Lazy Eye:Yes No
    Eye Turn:Yes No
    Eye Tumor:Yes No

Please list any family members with a history of other eye or medical problems.
List the relation and type of problem: