Patient Information
Prefix
- select -
Mr,
Miss,
Ms,
Ms.
Dr.
Prof.
Rev.
First Name
Last Name
Suffix
Street Address
Street Address 2
City
State
Zip
Phone Number
Email
Personal Information
Date Of Birth
Preferred Language
English
Spanish
French
Japanese
Race
Asian
Black and African American
Hispanic
Native Hawaiian and Pacific Islander
White
Ethnicity
Hispanic or Latino
Native Hawaiian and Pacific Islander
Not Hispanic or Latino
Marital Status
Divorced
Legally Separated
Married
Single
Widows
Other
Employment Status
Employed Full-time
Employed Part Time
Not Employed
Active Military
Retired
Self Employed
Student
Employer
Occupation
How were you referred to our office?
Friend and Family
Family Doctor
Ophthalmologist
Insurance Company
Newspaper
Television
Radio
Internet
Other
Eye History
Glasses History
Contact Lens History
Medical History
When, approximately, was your last eye exam?
Where did you get your last eye exam?
When, approximately, was your last physical exam?
Who is your primary care physician?
Do you drink alcohol?
No
Yes, 1 a week
Yes, 1 a day
Yes, 2-3 a day
Yes, 4 or more a day
Do you smoke?
No
Yes, 1/2 a day
Yes, 1 pack a day
Yes, 2-3 a day
Yes, more than 1 pack 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
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
Insurance Company Name
nsurance Company Phone Number
Identification Number
Group Number
Insured's Date of Birth
Patient's Relation to Insured
Secondary Insurance
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