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 (206) 244-1780. 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?  

Medical History


Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Patient Demographic Information
Hobbies:
Do you drink alcohol?
Smoking Status:

Patient Medical Information
Reason for Visit: Ocular Problems Summary:
Ocular Surgery: Medical Problems Summary:
Current Medications:       No current medicationsDrug Allergies:         No known drug allergies

Prescriptions/Over the Counter Eye Drops:
Vitamins/Supplements:
Major Injuries/Surgeries:
Who is your Primary Care Provider?
Do you have high blood pressure?

* Please remember to bring your insurance cards with you to your appointment. Thank you!


Family Medical History
You  Mom  Dad  Siblings  Grandparent  None Describe (If Needed)
Glaucoma                            
Mac Degen                            
RD/Ret                            
Cataract                            
Lazy Eye                            
 
Blood Pressure                            
Thyroid                            
Heart Disease                            
Cholesterol                            
Cancer                            
Diabetes                            
      If YOU have diabetes, what type?
     
      Year diagnosed: A1c:

Review of Systems - please provide an answer for each system drop-down
Allergy/Immune: Cardiovascular:
Constitutional: Ear/Nose/Throat:
Gastrointestinal: Genitourinary:
Blood/Lymph: Skin:
Musculoskeletal: Neurological:
Psychiatric: Respiratory:
Endocrine:

Eye Information
Last Eye Exam:
Doctor:

Visual TasksDistance in Inches
Near Vision:
Work:
Computer:

Do you have backup glasses?
Do you have sunglasses?
Are you interested in contacts?
Contact Lens Information
Comfort:
Vision:
Solution:
Average Wear Time:
Replacement:
How old are your current lenses?

* Please bring your contact lens prescription or boxes with you to your appointment. Thank you!





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