Patient Information and Medical History Form

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Patient Information

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

Title	First*	Last*	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev. Fr.

Address
City	St NC AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY ND OH OK OR PA RI SC SD TN TX UT VT VI VA WA WV WI WY	Zip

Hm Phone*
Cell Phone*
Wk Phone
Other Phone
Email
Preferred Contact By	Cell Phone Home Phone Work Phone Other Phone Text Message Email
DOB (mm/dd/yyyy)
Sex	Female Male
Marital Status	Annulled Divorced Domestic Partner Interlocutory Legally Separated Married Never Married Polygamous Widowed
Employment Status	Employed FT Student PT Student
Occupation/Grade
Employer/School
Parent/Guardian
Race	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Patient Declined to Specify
Ethnicity	Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify
Preferred Language	English Spanish

Who may we thank for referring you to our office?  

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Fr.

Address
City	St NC AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY ND OH OK OR PA RI SC SD TN TX UT VT VI VA WA WV WI WY	Zip
Hm Phone
Wk Phone

General Medical History

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Reason for Visit:	Secondary Reasons:

Medications: No Meds Used	Over The Counter Medications:

Vitamins:	Drug Allergies: No Known Drug Allergies

Please describe any injuries or surgeries you have had:

Primary Care Physician:

Last Visit:

1 week 1 month 3 months 6 months 1 year 2 years greater than 3 years Other

Reason:

Check up Annual Specific Other

Pregnant Or Nursing:

No Yes Unsure Other

Recent Tetanus Shot:

Yes No Other

Family Medical History

Unknown family history

Diabetes:

None Self Mother Father Grandparent Unknown Other

Type:

Type 1 Type 2 Other

Year Diagnosed:

1 yr 2 yrs 3-5 yrs 5-10 yrs 10+ yrs Other

HbA1C:

High Blood Pressure:	None Self Mother Father Grandparent Unknown Other	Describe:
High Cholesterol:	None Self Mother Father Grandparent Unknown Other	Describe:
Thyroid Disease:	None Self Mother Father Grandparent Unknown Other	Describe:
Heart Problems:	None Self Mother Father Grandparent Unknown Other	Describe:
Cancer:	None Self Mother Father Grandparent Unknown Other	Describe:

Eye History

Do you currently have any of these symptoms?:	None Itching Burning, Stinging Red Floaters Flashes Of Light Eye Injuries Eye Surgery Amblyopia Strabismus Cataracts Glaucoma Retinal Disorders Other
Do you take any of these eye medications?:	None Cromolyn NA 4% Visine Patanol Xalatan Travatan rewetting drops Elestat Vigamox Alphagan Refresh Theratears Genteal Pred Forte Lotemax Alrex Systane Blink Other

Last Eye Exam:

1 year 2 years 3 years Other

By Doctor:

Primary Vision Correction:

None Prescription Glasses Prescription Reading Glasses Soft Contacts Non-Prescription Reading Glasses Other

Do you:    Have back up glasses?

No Yes Other

Want new glasses?

Yes No Other

Contact Lens Wearers only

Type of contacts worn in the past:

None Disposable Conventional Colored RGP PMMA Cobalt Study Lens Soft Other

Cleaner:

None PureMoist Optifree Clear Care Boston Renu Biotrue Aquify Other

Disposal:

daily 2 weeks monthly weekly yearly Other

Wear Time:

>2 hours today All day Occ. Overnight Extended 8 hours 10 hours 12 hours Overnight Other

Days per week worn:

Hours per day worn:

Family Eye History

Macular Degen:	No Parents Siblings Grandparent Other	Glaucoma:	No Parents Sibling Grandparent Other
Retinal Detach:	No Parents Siblings Grandparent Other	Cataracts:	No Parents Siblings Grandparent Other
Lazy/Crossed Eye:	No Parents Siblings Grandparent Other

Review of Systems

General:	none fatigue fever loss of appetite weight gain weight loss Other	Ear/Nose/Throat:	none chronic cough congestion daytime drowsiness dry throat / mouth gasp while sleeping headache hearing problems heavy snoring morning headaches runny nose sinus problems sleep apnea tinnitus toothache Other
Skin:	none acne eczema itching psoriasis rosacea Other	Cardiovascular:	none chest pain heart disease high cholesterol hypertension racing heartbeat shortness of breath swollen feet/ankles vascular disease Other
Respiratory:	none asthma cronchitis cyanosis emphysema productive cough shortness of breath wheezing Other	Musculoskeletal:	none arthritis decreased range of motion muscle cramps pain/tenderness stiffness swelling weakness Other
Psychiatric:	none anxiety depression insomnia obsessive/compulsive paranoia suicidal violence Other	Gastrointestinal:	none abdominal pain acid reflux bloody stools constipation Crohn's disease dark urine diarrhea gastric reflux (GERD) IBS jaundice nausea ulcer vomiting Other
Endocrine:	none diabetes hypothyroid hyperthyroid Other	Blood/Lymph:	none anemia bleeding gums cuts slow to clot easy bruising hx of significant blood loss nosebleeds pale skin pounding in ears rapid heartbeat shortness of breath Other
Neurological:	none balance problems changes in senses dementia memory problems muscle weakness numbness, paralysis personality changes speech problems tremors vertigo Other	Genitourinary:	none impotence jaundice overactive bladder painful urination painful urination underactive bladder urgency in urination urinary incontinence Other
Immune:	none asthma hives itching mild allergy symptoms redness severe allergy symptoms sneezing swelling Other

Social History

Hobbies:

None Art Baseball Astronomy Boating Basketball Cooking Crafts Dancing Diving Football Fishing Golf Gardening Horseback Riding Hunting Models Needlepoint Painting Photography Piano Reading Running Roller Blading Softball Sewing Skiing Soccer Swimming Tennis Video Games Woodworking Other

STD's:

None Gonorrhea Syphilis Hepatitis HIV TB Other

Smoking Status:	Never smoker (<100 cigs equiv) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Current every day smoker Unknown if ever smoked Other	Type:	None Cigarettes Chewing Tobacco Other	How Long:
Alcohol Use:	No Yes Occasionally Socially Other	Type:	None Beer Wine Hard Liquor Other	How Long:
Illegal Drug Use:	No Yes Other	Type:		How Long

Race:

White Black or African American Asian Patient Declined to Specify American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Other Race Other

Ethnicity:

Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Other

Preferred Language:

English French German Spanish Other

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