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)
Title   First*Last*MISuffixNickname
 
Address
City State  Zip
Home Phone
Cell Phone*
Email
Preferred Contact By
DOB (mm/dd/yyyy)  
SSN:
Sex Female Male
Occupation/Grade
Employer/School
Parent/Guardian

Who may we thank for referring you to our office?  

Insurance Information

Medical Insurance
Insurance Name:
I am not the primary subscriber on this account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Insurance Information

Vision Insurance
Insurance Name:
I am not the primary subscriber on this account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

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

Medical History


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

Eye History
Whom May We Thank For Referring You?
Reason for Visit:
What Would You Like To Discuss At Your Visit?
Last Eye Exam:
Last Eye Doctor:


Do You Have Glasses?
Do you have backup glasses?
Do you have sunglasses?
Are you interested in contacts?
Contact Lens History
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!


Patient and Family History
List Any Eye Surgeries You Have Had:
Current Medications: (including OTC and any eye drops) Drug Allergies:        
No current medicationsNo known drug allergies

Vitamins/Supplements:
Major Injuries/Surgeries:
Who is your Primary Care Provider?

You  Mom  Dad  Siblings  Grandparent  None Describe (If Needed)
Glaucoma                            
Macular Degen                            
Retinal Detachment                            
Cataract                            
Lazy Eye                            
 
Blood Pressure                            
Thyroid Disease                            
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:





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