Patient Information and Medical History Form

Patient Information and Medical History Form

Patient Information

Billing Information

General Medical History

Review of Systems

Ocular History

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 (509) 487-0600. We can always change the data in the office if you are unsure about what to enter in any of the fields.

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

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

How did you hear about us?*

May we thank them for referring you?

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:

General (e.g., cancer, develpmental disorders, chronic fatigue syndrome)

Ear, Nose, Throat (e.g., dry mouth, hearing loss, sinus inflammation)

Cardiovascular (e.g., heart disease, high blood pressure, high cholestorol, history of stroke)

Respiratory (e.g., COPD, asthma, sleep apnea)

Genital, Kidney, Bladder (e.g., pregnant/nursing, prostate disease/cancer, kidney disease, STDs)

Gastrointestinal (e.g., inflammatory bowel, Crohn's disease, celiac disease, acid reflux)

Endocrine (e.g., diabetes type 1 or 2, thyroid dysfunction, hormonal dysfunction)

Muscles, Bones, Joints (e.g., rheumatoid arthritis, osteoarthritis, fibromyalgia, ankylosing spondylitis)

Skin (e.g., herpes simplex/cold sores, herpes zoster/shingles, rosacea, psoriasis, eczema)

Neurological (e.g., epilepsy, migraine, multiple sclerosis)

Psychiatric (e.g., depression, anxiety, bipolar, attention deficit)

Blood/Lymph (e.g., anemia, leukemia)

Allergy/Immune (e.g., environmental allergies, medication allergies, Sjogren's syndrome, lupus)

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

Check the box for any conditions that apply:

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 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 glassess?
Are you interested in contacts?
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?

Describe (type, when were you diagnosed, etc)

Hypertension

Cardiovascular