Patient History Form

Please complete the information below and submit the form online. This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Please help us take better care of your overall health by completing the following form

Name*

First Middle Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Number*

Please provide a telephone number, with area code, so we can contact you.

Cell Phone

Work Phone

Will you be using your FSA Card or HSA Card?

Yes
No

You can use your FSA/HSA benefits towards any purchase at our practice.

Email Address

Please provide your email address.

Employer

Occupation*

Date of Birth*

Social Security Number (last 4 digits only!)

Please enter a number from 0000 to 9999.

Race/Ethnicity

Preferred Language

Gender

Female
Male

Who may we thank for referring you to our office?*

Date of Last Medical Exam

Name of Medical Doctor

Doctor's Phone Number

Date of Last Eye Exam*

Name of Previous Eye Physician

Spouse or Guardian (If Applicable)

PLEASE CHECK ALL THAT APPLY

OCULAR HISTORY

Other: Please Specify

OCULAR SURGERY

Other: Please Specify

This field is hidden when viewing the form

If Other Eye Disorders or Surgeries, please explain:

Do you wear glasses?

No
Yes

If Yes, how old is your current pair of glasses?

Please bring your most recent pair of glasses to your eye exam.

Do you wear sunglasses?

No
Yes

Do you wear contact lenses?

No
Yes

If Yes, how old is your current pair of contact lenses?

Do you sleep in your contact lenses?

No
Yes

Type of Contact Lenses:

Rigid
Soft
Extended Wear
Other

If Other, please explain:

Are your contact lenses comfortable?

No
Yes

What type(s) of activities do you engage in outdoors? Check all that apply.

If Other, please explain:

On average, how many hours per day do you spend looking at a screen (computer, phone, tablets, etc)?*

MEDICAL HISTORY

List any medications you take, including oral contraceptives, aspirin, over-the-counter medicines, etc.:*

Include Name of Medication, Dosage, Frequency Taken

Do you have any allergies to medications?*

No
Yes

If Yes, list medication(s) and reaction(s) below:

List all major injuries, surgeries and/or hospitalizations you have had:

Are you pregnant or nursing?

No
Yes

Have you ever been exposed to or infected with:

Gonorrhea
Hepatitis
HIV
Syphillis

REVIEW OF SYSTEMS

CARDIOVASCULAR

Elevated Cholesterol
Heart Disease
Hypertension

ENDOCRINE

GASTROINTESTINAL

Acid Reflux
Cancer, Colon, Liver, Lung
Hepatitis
Gastritis

GENITOURINARY

Ovarian Disorder
Prostate Disorder

EAR, NOSE, MOUTH, THROAT

Dry Mouth
Ear Infection
Sinusitis

IMMUNOLOGIC

NEUROLOGICAL

RESPIRATORY

Asthma
Sleep Apnea
Lung Disease
Tuberculosis

HEMATOLOGIC/LYMPHATIC

Anemia
Blood Disorder
Sickle Cell Disease

INTEGUMENTARY (SKIN)

Acne
Acne Rosacea
Dermatitis
Lupus

MUSCULOSKELETAL

Arthritis
Muscular Dystrophy
Myasthenia Gravis
Rheumatoid Arthritis

PSYCHIATRIC

Anxiety Disorder
Dementia
Depression
Mood Disorder

Patient History Form

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