Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.
This form contains confidential information and is delivered to your doctor through a secure Internet connection.
Patient Information Name* Mr. Mrs. Miss Ms. Dr. Prof. Rev. Prefix First Last Suffix
Address*
Personal Information Gender* Social Security Number (last 4 digits only!) Preferred Language* English Spanish French Japanese Decline to specify
Race* American Indian or Alaska Native Asian Black or African American Hispanic Native Hawaiian or Pacific Islander White Decline to specify
Ethnicity* Decline to specify Hispanic or Latino Native Hawaiian or other Pacific Islander Not Hispanic or Latino
Marital Status Divorced Legally Separated Married Single Widowed Other
Employment Status Employed Full-Time Employed Part-Time Not Employed On Active Military Duty Retired Self-Employed Student Full-Time Student Part-Time Other
How were you referred to our office? Friend or Family Family Doctor Ophthalmologist Insurance Company Newspaper Television Radio Received Mailing Internet Other Optometrist Other
Communication Preference Email Postal Telephone
Eye History Please check off any current conditions you suffer from
Glasses History Do you wear glasses?* What glasses do you own? How many hours a day do you use a computer? How many inches away, approximately, do you sit from your computer monitor? Please check off any current conditions you suffer from
Contact Lens History Do you wear contact lenses?* What is your typical wearing schedule? In hours per day: What is your typical wearing schedule? In days per week: Please check off all that apply to you
Medical History Do you drink alcohol? No Yes, 1 per week Yes, 1 per day Yes, 2 or 3 per day Yes, 4 or more per day
Do you smoke? No Yes, 1/2 a pack per day Yes, 1 pack per day Yes, more than 1 pack per day
Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)
Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)
Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)
Please list all hospital surgeries you have ever had:
Please list all prescription and over-the-counter medications you take and for what conditions
Please list all drug allergies you have
Please check off any current conditions you suffer from Chronic fever, unexpected weight loss/gain, fatigue Ear/nose/throat problems ( eg. Hearing loss, sinus problems, sore throat) Heart problems (eg. Chest pain, irregular heart beat, swelling of feet, cold hands or feet) Respiratory problems (eg. Shortness of breath, wheezing, coughing) Gastrointestinal problems (eg. Heartburn, abdominal pain, diarrhea, vomiting) Genitourinary problems (eg. Painful urination, blood in urine, sex organ problems) Musculoskeletal problems (eg. Muscle aches, joint pain, swollen joints) Skin problems (eg. Rashes, excessive dryness, growths or lumps) Neurological problems (eg. Numbness, weakness, headaches, “blackouts”) Psychiatric problems (eg. Depression, anxiety) Endocrine problems (eg. Frequent urination, thirst, feeling hot or cold all the time) Blood/Lymph problems (eg. Bruising, weakness, unusual paleness, swollen glands) Immune problems (eg. Frequent infections, allergic reactions to foods, dust, pollens)
Primary Insurance Please bring all insurance cards with you to your appointment.
Address Insured's Name
Secondary Insurance Do you have secondary insurance? If you have coverage through another plan/organization, please fill in the details below.
Address Insured's Name
Comments If you have any comments you would like to add, please enter them here.
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