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 or text 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

Title	First*	Last*	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev. Fr.

Home Phone
Cell Phone*
Email
Preferred Contact By	Text Cell Phone Home Phone
DOB (mm/dd/yyyy)  *
Sex	Female Male

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

Medical History

Eye History

Reason for Visit:

Routine eye exam (glasses only) Routine eye exam (glasses and contacts) Medical visit Other

What Would You Like To Discuss At Your Visit?

Last Eye Exam:
Last Eye Doctor:

Do You Have Glasses?	Yes No Other
Do you have backup glasses?	Yes No Other
Do you have sunglasses?	Yes No Transitions Clip ons Polarized Other
Are you interested in contacts?	Yes No

Patient and Family History

	You	Mom	Dad	Siblings	Grandparent	None	Describe (If Needed)
Glaucoma
Macular Degen (AMD)
Retinal Detachment
Cataract
Lazy Eye

List Any Eye Surgeries You Have Had:

 

	You	Mom	Dad	Siblings	Grandparent	None	Describe (If Needed)
High Blood Pressure
Thyroid Disease
Heart Disease
High Cholesterol
Cancer
Diabetes

If YOU have diabetes, what type?

None Personal History of Gestational Diabetes Pre-Diabetes Type 1 Diabetes Mellitus Type 2 Diabetes Mellitus Other

Year diagnosed: A1c:

Current Medications: (including OTC and any eye drops)*	Drug Allergies:*
No current medications	No known drug allergies

Vitamins/Supplements:	Major Injuries/Surgeries:

Who is your Primary Care Provider?
Who may we thank for referring you to our office?

You're Done! Please hit the Submit button below.