"*" indicates required fields

1Patient Info

2Medical History

3Ocular History

Patient Information

Name*

Prefix First Middle Last Suffix

Address*

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

Home Phone

Cell Phone*

Work Phone

Other Phone

Email*

Preferred Contact By*

Date of Birth*

MM slash DD slash YYYY

Sex*

Male

Female

Other

Enter your preferred pronoun

Employment Status

Full Time

Part Time

Student

Other

Occupation/Grade

Employer/School

Parent/Guardian

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

Do you have Medical insurance and/or a Vision Plan?

Medical Insurance

Vision Plan

Name of Medical Insurance*

ID/Group of Medical Insurance*

Last 4 Digits of Social*

Name of Vision Plan*

ID/Group of Vision Plan*

Last 4 Digits of Social*

General Medical History

Primary physician's name and phone

When was your last Medical 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

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 use lash extensions or serums?

Do you have sunglasses?

Do you have back-up glasses?

Are you interested in contacts?

Yes

Contact Lens Evaluation Consent

Yes, I would like a contact lens evaluation today in order to update my contact lens prescription and have the ability to purchase contact lenses for the next 12 months. I understand that the evaluation fee must be paid at the time of service.

Explanation of Contact Lens Evaluation Fees

An annual routine eye exam includes glaucoma screening, dilation, refraction (to obtain your glasses prescription), and overall eye health evaluation.

If you are a contact lens wearer, our doctors can also evaluate your contact lenses and write a contact lens prescription at your routine eye exam appointment. The contact lens evaluation is a separate fee, and most insurance companies do not fully cover the
contact lens evaluation portion of the exam.

A contact lens evaluation is required each year in order to maintain a valid prescription. We offer routine contact lens checks as needed at no charge for 3 months following your exam. After that time period, there may be a charge associated with a contact lens appointment.

Patients who do not consent/want a contact lens evaluation will not be able to purchase contact lenses without an updated contact lens prescription.

Do you currently wear them?

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

I agree to receive my prescription copies via email

Signature

Hidden

Date

MM slash DD slash YYYY

Health History Form

Patient Information

Billing Information

General Medical History

Check the box for any conditions that apply:

Review of Systems

Ocular History

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