Patient Health History Form

Patient Health History Form

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.
*Asterisk denotes required field

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
Full Name
Address
Phone Number
Daytime Phone
Cell Phone
Email Address
Personal Information
Gender
Date of Birth

MonthDayYear
Social Security Number (last 4 digits only!)
Please enter a value between 0000 and 9999.
Preferred Language
Race
Ethnicity
Marital Status
Employment Status
Employer
Occupation
How were you referred to our office?
Communication Preference
Eye History
Please check off any current conditions you suffer from
Glasses History
Do you wear glasses?
Contact Lens History
Do you wear contact lenses?
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?
Who is your primary care physician?
Do you drink alcohol?
Do you smoke?
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
lease check off any current conditions you suffer from
Primary Insurance

Please bring all insurance cards with you to your appointment.
Insurance Company Name
Insurance Company Phone Number
Address
Insured's Name
Group Number
Date of Birth

MonthDayYear
Patient's Relation to Insured
Secondary Insurance
Do you have secondary insurance?
Comments
If you have any comments you would like to add, please enter them here.
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Health Information Protection *
Should be Empty:

Patient Health History Form

Patient Information

Personal Information

Eye History

Glasses History

Contact Lens History

Medical History

Primary Insurance

Secondary Insurance

Comments

Privacy Policy