Spectacle- Modern pain-free eye exams

Patient Information

Billing Information

General Medical History

Review of Systems

Ocular History

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Health History Form

Patient Information and Medical History Form

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*required (enter first and last name and either a home OR cell phone, view three PDF forms towards bottom of page, and sign prior to submitting)

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?

Is The Billing Address the Same?

Title	First	Last	MI	Suffix

Address

City	St	Zip
Hm Phone
Wk Phone

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

Check the box for any conditions that apply:

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?

Please list any problems you are currently having anywhere, from head to toe (Leave any normal categories blank):

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)

Who was your previous eye doctor/office?:
When was your last eye exam?
What is the primary reason for your visit today?

Check the box for any conditions that apply:

List any eye surgeries (i.e. Lasik, cataract, etc.), injuries, or infections & approx. dates:

List any other significant eye problems you have had:

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

List any other vision 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

How many hours/day do you typically spend using a computer or other digital devices?
If you are having complaints with computer work, how far is the monitor from your eyes?
How many hours/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?	I currently wear them (Fill section below)
Contact Lens Wearers Only
What brand of contacts do you currently wear?
Rate this brand's overall comfort (1-10).
What disinfecting solution do you use?
How many hours/day do you usually wear your lenses?
Will you run out of your contact lens supply between now and your next eye exam?
How often do you replace your lenses?
How old is your current pair of contacts?

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*I have read the Enhanced Screening Options.

Signature:

Date:

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Describe (type, when were you diagnosed, etc)

Hypertension

Cardiovascular

ALPHABET
DISTRICT
2250 NW LOVEJOY
ST.
PORTLAND, OR
97210
P 503.719.5179

office@spectaclepdx.com

CEDAR HILLS
2905 SW CEDAR HILLS BLVD. STE
100
ST.
BEAVERTON, OR 97005
P 503.828.9152

cedarhills@spectaclepdx.com

#spectaclepdx