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Located at 339 NW 9th Ave in Portland, OR

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Home » Contact Us » Health History Form

Health History Form

Patient Information
Name*
Prefix First Middle Last Suffix
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Hm Phone
Cell Phone*
Wk Phone
Other Phone
Email*
Preferred Contact By
Date of Birth
Date Format: MM slash DD slash YYYY
Sex
- Male
- Female
Marital Status
Employment Status
- Employed
- FT Student
- PT Student
Occupation/Grade
Employer/School
Parent/Guardian
Race
Ethnicity
Preferred Language
Who may we thank for referring you to our office?
Billing Information
Is The Billing Address the Same?
Name
Prefix First Middle Last Suffix
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Hm Phone
Wk Phone
General Medical History
Primary physician's name and phone
When was your last physical exam?
Check the box for any conditions that apply:
Hypertension
- You
- Mom
- Dad
- Sib
- Other
Describe (type, when were you diagnosed, etc)
Thyroid
- You
- Mom
- Dad
- Sib
- Other
Describe (type, when were you diagnosed, etc)
Cardiovascular
- You
- Mom
- Dad
- Sib
- Other
Describe (type, when were you diagnosed, etc)
Cancer
- You
- Mom
- Dad
- Sib
- Other
Describe (type, when were you diagnosed, etc)
Diabetes
- You
- Mom
- Dad
- Sib
- Other
Describe (type, when were you diagnosed, etc)
If YOU are diabetic, when were you diagnosed?
Last A1C level?
Are you Pregnant or Nursing?
List ALL major injuries or surgeries you have had and approx dates:
List any other medical conditions you have had, including non-drug allergies:
List all Rx and over-the-counter medications you currently take:
List any vitamins or supplements you currently take:
List any drug allergies you have:
Smoking Status
Alcohol Use
Do you live alone?
Review of Systems
Please list any problems you are currently having anywhere, from head to toe (Leave any normal categories blank)
General (e.g., fever, fatigue, loss of appetite, unexplained weight loss/gain)
Ear, Nose, Throat (e.g., sinus/nasal congestion, nose bleeds, dry mouth/throat, sleep apnea, hearing problems)
Cardiovascular (e.g., chest pain, racing heartbeat, swollen feet/ankles, TIAs)
Respiratory (e.g., chronic cough, shortness of breath, wheezing)
Genital, Kidney, Bladder (e.g., bladder/urinary problems, pain, discharge, menstrual changes, impotence)
Gastrointestinal (e.g., constipation, diarrhea, gastric reflux (GERD), jaundice, nausea, vomiting)
Endocrine (e.g., heat or cold intolerance, thinning hair, excess thirst, excess urination)
Muscles, Bones, Joints (e.g., pain, stiffness, swelling, weakness, limited movements)
Skin (e.g., dry, itchy, flaky, rash, growths, bumps, redness, discoloration)
Neurological (e.g., headaches, numbness/tingling, tremors, poor balance, dementia, speech problems)
Psychiatric (e.g., depression, anxiety, sleep problems, paranoia, obsessive/compulsive)
Blood/Lymph (e.g., anemia, bleeding gums, delayed clotting, unexplained bruising)
Allergy/Immune (e.g., swollen lymph nodes, itching, sneezing, runny nose/eyes)
Ocular History
Who was your previous eye doctor/office?
When was your last eye exam?
What is the primary reason for your visit today?
Check the box for any conditions that apply
Glaucoma
- You
- Mom
- Dad
- Sib
- Other
Describe (type, when diagnosed, which eye(s), treatment)
Macular Degeneration
- You
- Mom
- Dad
- Sib
- Other
Describe (type, when diagnosed, which eye(s), treatment)
Retinal problems
- You
- Mom
- Dad
- Sib
- Other
Describe (type, when diagnosed, which eye(s), treatment)
Cataracts
- You
- Mom
- Dad
- Sib
- Other
Describe (type, when diagnosed, which eye(s), treatment)
Lazy Eye/Eye Turn
- You
- Mom
- Dad
- Sib
- Other
Describe (type, when diagnosed, which eye(s), treatment)
List any eye surgeries (i.e. Lasik, cataract, etc.), injuries, or infections & approx. dates
List any other significant eye problems you have had
List all Rx and over-the-counter eye medications you currently use
List any other vision complaints you are currently having such as: blurred vision, headaches, eyestrain, double vision, or losing your place when reading itching, burning, redness, pain, sensitivity to light, watering, crusting or mucus discharge seeing rainbows around white lights at night, flashes of light or dark spots/squiggles/webs
How many hours/day do you typically spend using a computer or other digital devices?
If you are having complaints with computer work, how far is the monitor from your eyes?
How many hours/day do you typically spend reading books, magazines, etc?
What are your hobbies/sports activities?
Do you have sunglasses?
Do you have back-up glasses?
Are you interested in contacts?
I currently wear them (Fill section below)
What brand of contacts do you currently wear?
Rate this brand's overall comfort (1-10).
What disinfecting solution do you use?
How many hours/day do you usually wear your lenses?
Will you run out of your contact lens supply between now and your next eye exam?
How often do you replace your lenses?
How old is your current pair of contacts?
*
- I agree to the privacy policy
Signature
Date
Date Format: MM slash DD slash YYYY

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Patient History Form

Email Us

The Eye Studio

339 NW 9th Ave
Portland, OR 97209

Phone: 503-219-0023
Fax: 503-219-0024
Email: info@the-eyestudio.com
(Do not send personal health information by email.)

Monday: 9:00 AM - 6:00 PM
Tuesday: 9:00 AM - 6:00 PM
Wednesday: 9:00 AM - 6:00 PM
Thursday: 9:00 AM - 6:00 PM
Friday: 9:00 AM - 6:00 PM
Saturday: 9:00 AM - 4:00 PM
Sunday: Closed

Visit The Eye Studio in Portland, Oregon

Our office is located at 339 NW 9th Ave, Portland, OR, 97209. Please enter your zip code or city, state below for door-to-door directions.

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What We Do

Hours & Location
Our Team
Eyecare Services
Our Specialties
Optical Boutique
Insurance

Hours & Location
Our Team
Eyecare Services
Our Specialties
Optical Boutique
Insurance

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Home
Contact Us
What’s New
Disclaimer
Privacy Policy

Our Address

The Eye Studio - Located at 339 NW 9th Ave, Portland, OR 97209 Phone: 503-219-0023 www.the-eyestudio.com

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