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 714-486-3315. 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)

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 as above?

TitleFirstLastMISuffix
Address
City St  Zip
Hm Phone  
Wk Phone

Primary Vision Insurance

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Please check here if you are not the primary on the account: Not Primary

Please fill in the following information for the Primary Member on the account
Name:Last, First, MI
Patient's relationship to Primary Member:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
* SSN:
Employer/School:

* We are unable to authorize your insurance benefits without this information. Please provide at least the last 4 digits.

Secondary Vision Insurance

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Please check here if you are not the primary on the account: Not Primary

Please fill in the following information for the Primary Member on the account
Name:Last, First, MI
Patient's relationship to Primary Member:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
* SSN:
Employer/School:

* We are unable to authorize your insurance benefits without this information. Please provide at least the last 4 digits.

Medical Insurance

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Please check here if you are not the primary on the account: Not Primary

Please fill in the following information for the Primary Member on the account
Name:Last, First, MI
Patient's relationship to Primary Member:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
* SSN:
Employer/School:

* We are unable to authorize your insurance benefits without this information. Please provide at least the last 4 digits.

General Medical History

(leave blank if not applicable)

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

Check the box for any conditions that apply:

You Mom Dad Sib No Describe (type, when were you diagnosed, etc)
Hypertension
Thyroid
Cardiovascular
Cancer
Diabetes
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?  

Review of Systems

Please list any problems you are currently having anywhere, from head to toe:


(leave blank if not applicable)

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

(leave blank if not applicable)

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

Check the box for any conditions that apply:

You Mom Dad Sib No Describe (type, when diagnosed, which eye(s), treatment,etc)
Glaucoma
Macular Degeneration
Retinal problems
Cataracts
Lazy Eye/Eye Turn
List any major eye injuries, infections or surgeries and 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 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 spend using the computer or other
digital devices, reading books or magazines, and/or playing sports?:
Contact Lens Wearers Only
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?

For Vision Therapy

(leave blank if not applicable)

Grade: School:
Teacher: Subject:
      ADD/ADHD
      Autism
      Learning Disorder
        Other Delays:  
        Therapies:  

Symptom Checklist:

Please check all the symptoms that apply for the patient:

HA
Diplopia
Crossing Eye
Wandering Eye
Lazy Eye
Fatigue/strain w/reading
Other
Letter reversals
Losing place while reading
Omitting small words when reading
Transposing letters/#s (ie 12 for 21)
Dislike reading
Words swim/move/jump
Slow reader
Poor eye hand cord
Can't keep eye on ball
Poor handwriting
Poor memory
Can't visualize
R/L confusion
Difficulty copying from board

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