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	State  WA 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 NC NE NV NH NJ NM NY ND OH OK OR PA RI SC SD TN TX UT VT VI VA 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	Never Married Married Domestic partner Interlocutory Polygamous Divorced Annulled Legally Separated 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 French Chinese Arabic Russian Patient Declined to Specify

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	State  WA 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 NC NE NV NH NJ NM NY ND OH OK OR PA RI SC SD TN TX UT VT VI VA WV WI WY	Zip
Hm Phone
Wk Phone

Insurances

Primary Vision

Insurance Information

Insurance Name:	None AARP Healthcare Options Aetna Health Plans ASSURANT Asuris Northwest Health Ballard Terminal Railroad Co,LLC Beech Street Corporation Bridgespan Health Company Carpenters Trust Of Western WA Cigna Cigna Medicare Consolidated Health Plans Coordinated Care Coventry Health Care Ntnl Ntwrk Dept. Social & Health Services Drico Recovery First Choice Gilsbar, Inc. Great West Life Group Health Options Guarantee Trust Life Guardian Life Insurance Company Health Plus Highline Medical Service HMA Humana Kitsap Physicians Service Labor & Industries Lifewise LOOMIS March Vision Care MEDICARE Medimet Vision Mega Life & Health Insurance MetraHealth Molina Healthcare Mutual Of Omaha(Woodward Health) Nippon Life Insurance Northwest IronWorkers Health & Security Trust Fund ODS Companies Office Of Disability Insurance OPERATIN Opticare Pacific Care Secure Horizons Physicians Care Network/Plyclnc PREMERA Principal Life Insurance Company Providence Health System QUALMED Railroad Medicare Regence (Claims) Regence Federal Employee Program Regence Group Administrators Regence Uniform Medical Plan Rehn & Associates Seattle Area Plumbling & Pipefitting Industry Health Plan Sound Path Health Stirling Benefits Superior Vision Services The Laser Center Tricare For Life Trusteed Plans Service Corporation United Health Care US Family Health Plan Vision Service Plan VSP-MANG VSP-PRIM VSP Med Vision Washington Employers Trust Washington Physician Service Welfare And Pension Admin.
Insurance Plan:
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:

Secondary Vision

Insurance Information

Insurance Name:	None AARP Healthcare Options Aetna Health Plans ASSURANT Asuris Northwest Health Ballard Terminal Railroad Co,LLC Beech Street Corporation Bridgespan Health Company Carpenters Trust Of Western WA Cigna Cigna Medicare Consolidated Health Plans Coordinated Care Coventry Health Care Ntnl Ntwrk Dept. Social & Health Services Drico Recovery First Choice Gilsbar, Inc. Great West Life Group Health Options Guarantee Trust Life Guardian Life Insurance Company Health Plus Highline Medical Service HMA Humana Kitsap Physicians Service Labor & Industries Lifewise LOOMIS March Vision Care MEDICARE Medimet Vision Mega Life & Health Insurance MetraHealth Molina Healthcare Mutual Of Omaha(Woodward Health) Nippon Life Insurance Northwest IronWorkers Health & Security Trust Fund ODS Companies Office Of Disability Insurance OPERATIN Opticare Pacific Care Secure Horizons Physicians Care Network/Plyclnc PREMERA Principal Life Insurance Company Providence Health System QUALMED Railroad Medicare Regence (Claims) Regence Federal Employee Program Regence Group Administrators Regence Uniform Medical Plan Rehn & Associates Seattle Area Plumbling & Pipefitting Industry Health Plan Sound Path Health Stirling Benefits Superior Vision Services The Laser Center Tricare For Life Trusteed Plans Service Corporation United Health Care US Family Health Plan Vision Service Plan VSP-MANG VSP-PRIM VSP Med Vision Washington Employers Trust Washington Physician Service Welfare And Pension Admin.
Insurance Plan:
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:

Primary Medical

Insurance Information

Insurance Name:	None AARP Healthcare Options Aetna Health Plans ASSURANT Asuris Northwest Health Ballard Terminal Railroad Co,LLC Beech Street Corporation Bridgespan Health Company Carpenters Trust Of Western WA Cigna Cigna Medicare Consolidated Health Plans Coordinated Care Coventry Health Care Ntnl Ntwrk Dept. Social & Health Services Drico Recovery First Choice Gilsbar, Inc. Great West Life Group Health Options Guarantee Trust Life Guardian Life Insurance Company Health Plus Highline Medical Service HMA Humana Kitsap Physicians Service Labor & Industries Lifewise LOOMIS March Vision Care MEDICARE Medimet Vision Mega Life & Health Insurance MetraHealth Molina Healthcare Mutual Of Omaha(Woodward Health) Nippon Life Insurance Northwest IronWorkers Health & Security Trust Fund ODS Companies Office Of Disability Insurance OPERATIN Opticare Pacific Care Secure Horizons Physicians Care Network/Plyclnc PREMERA Principal Life Insurance Company Providence Health System QUALMED Railroad Medicare Regence (Claims) Regence Federal Employee Program Regence Group Administrators Regence Uniform Medical Plan Rehn & Associates Seattle Area Plumbling & Pipefitting Industry Health Plan Sound Path Health Stirling Benefits Superior Vision Services The Laser Center Tricare For Life Trusteed Plans Service Corporation United Health Care US Family Health Plan Vision Service Plan VSP-MANG VSP-PRIM VSP Med Vision Washington Employers Trust Washington Physician Service Welfare And Pension Admin.
Insurance Plan:
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:

Secondary Medical

Insurance Information

Insurance Name:	None AARP Healthcare Options Aetna Health Plans ASSURANT Asuris Northwest Health Ballard Terminal Railroad Co,LLC Beech Street Corporation Bridgespan Health Company Carpenters Trust Of Western WA Cigna Cigna Medicare Consolidated Health Plans Coordinated Care Coventry Health Care Ntnl Ntwrk Dept. Social & Health Services Drico Recovery First Choice Gilsbar, Inc. Great West Life Group Health Options Guarantee Trust Life Guardian Life Insurance Company Health Plus Highline Medical Service HMA Humana Kitsap Physicians Service Labor & Industries Lifewise LOOMIS March Vision Care MEDICARE Medimet Vision Mega Life & Health Insurance MetraHealth Molina Healthcare Mutual Of Omaha(Woodward Health) Nippon Life Insurance Northwest IronWorkers Health & Security Trust Fund ODS Companies Office Of Disability Insurance OPERATIN Opticare Pacific Care Secure Horizons Physicians Care Network/Plyclnc PREMERA Principal Life Insurance Company Providence Health System QUALMED Railroad Medicare Regence (Claims) Regence Federal Employee Program Regence Group Administrators Regence Uniform Medical Plan Rehn & Associates Seattle Area Plumbling & Pipefitting Industry Health Plan Sound Path Health Stirling Benefits Superior Vision Services The Laser Center Tricare For Life Trusteed Plans Service Corporation United Health Care US Family Health Plan Vision Service Plan VSP-MANG VSP-PRIM VSP Med Vision Washington Employers Trust Washington Physician Service Welfare And Pension Admin.
Insurance Plan:
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:

 

General Medical History

Primary physician's name and clinic
What pharmacy do you normally use?

If you are diabetic, what type?	history of gestational diabetes Pre-diabetes Type 1 Type 2
when were you diagnosed?	Last A1C level?

List ALL major injuries or surgeries you have had:

List all Rx and over-the-counter medications you currently take: No Meds

List any vitamins or supplements you currently take:

List any drug allergies you have (include type of reaction): No Known Allergies

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
Alcohol Use	No Yes Occasionally Socially 1 drink per day Multiple drinks per day
Do you live alone?	No Yes assisted living nursing home

 

Review of Systems

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

General Health (Constitution) Problems (e.g., ADD, cancer, fatigue, insomnia, loss of appetite, weight loss/gain)

(Ear, Nose, Throat) Problems (e.g., dry mouth, hearing loss, sinus condition, vertigo)

(Cardiovascular) Problems (e.g., atherosclerosis, A-fib, congestive heart failure, blood pressure, TIA, vascular dz)

(Respiratory) Problems (e.g., asthma, bronchitis, COPD, emphysema, pneumonia, sleep apnea)

Reproductive, (Genitourinary) Disorders (e.g., BPH, erectile dysfunction, herpes, kidney problems, STD)

(Gastrointestinal) Problems (e.g., acid reflux/GERD, celiac, colitis, Crohns, gall bladder, hepatitis, IBS)

(Endocrine) Disorders (e.g., diabetes, Graves, hormone disorder, pituitary disorder, thyroid condition)

Muscles, Bones, Joint (Musculoskeletal) Disorders (e.g., arthritis, fibromyalgia, osteoarthritis, osteoporosis)

Skin (Integumentary) Disorders (e.g., acne, basal cell, cold sores, eczema, gout, psoriasis, rosacea, shingles)

(Neurological) Disorders (e.g., Alzheimers, autism, headaches, dementia, epilepsy, MS, Parkinsons, stroke)

(Psychiatric) Disorders (e.g., ADD/ADHA, anxiety, bipolar, depression, schizophrenia)

Blood, Cholesterol, (Blood/Lymphatic) Disorders (e.g., anemia, high cholesterol, high triglycerides, sarcoidosis)

Allergies (Immune) Disorders (e.g., allergies, HIV, herpes simplex, rheumatoid arthritis, shingles, lupus)

 

Ocular History

Who was your previous eye doctor?

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 long do you typically spend using a computer or other digital devices daily?

all day use rarely uses moderate use Other

What are your hobbies/sports activities?
Do you have sunglasses?
Do you have back-up glassess?
Are you interested in contacts?

What type of vision correction do you use? (leave blank if none): Contacts Glasses

 

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