Patient Information and Medical History Form

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Patient Information

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

TitleFirst*Last*MISuffixNickname
Address  
City  State   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  State   Zip
Hm Phone 
Wk Phone


Insurances

Primary Vision

Insurance Information
Insurance Name:
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:
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:
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:
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?  
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
Alcohol Use
Do you live alone?  

 

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?
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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