MedicalHistoryForm

Medical History Form

Welcome to our office. Please fill out this form as thoroughly as possible. A save button is located at the bottom of the form in the event that you need to continue at a later time.
Full Name

First NameMiddle NameLast Name
Todays date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState

Zip Code
Gender
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Age
Last Four Digits of Social Security Number (SSN)
*SSN will be used for gathering insurance information prior to your appointment
Email
example@example.com
Cell Phone Number

Area CodePhone Number
Occupation and Employer
If student: Grade level
If student: School name
How did you hear about our office?

Other
Reason for eye exam? (check all that apply)

Other
Medical Insurance Name

Other
Does your company offer a Flexible Spending Plan (FSA)?
Do you participate in the FSA Program?
Does your company offer a Flexible Spending Account (FSA), Health Savings Account (HSA) or Health Reimbursement Account (HRA) or Medical Reinbursment Account (MRA)?
Do you currently participate in the FSA, HSA or MRA Program?
Date of Last Eye Exam

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Years of Current Glasses/Contacts
Name of Previous Optometrist or Ophthalmologist. In what city?
Date of Last Physical

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Physician's Name
Location of Medical Care

Other
Check the conditions that apply to YOU:

Other
Check the eye conditions/diseases that apply to YOU:

Other
Check the conditions that apply FAMILY members:

Other
Check the eye conditions/diseases that apply to any FAMILY members:

Other
Are you currently taking any medications or eye drops?
Please List Medications and Dosages
Do you have any allergies? (ex: food, medication or metals?)
Please list any additional allergies:
Have you ever had any infection / disease / injury / surgery of the eye?
Please list any infections, diseases, or injuries of the eye, specifying which eye and date of occurrence:
Please list past and planned eye surgeries, specifying the eye (right or left) and the date:
Do you notice floaters, flashes of light or double vision?
Since when and which eye?
Do you experience regular headaches?

Do you currently or have you ever consumed alcohol, cigarettes/tobacco, or any other substances?
If so which?

Other
How many packs or drinks per week? (If monthly please specify)
Do you get motion sickness, fall asleep when reading or get dizzy at 3D movies?
Have you or any immediate family members had cancer?
Do you experience eye strain or fatigue on a computer?
Please upload your most recent glasses and/or contact lens prescriptions:

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Do you have separate computer glasses?
Do you have or wear prescription sun glasses?
Do you wear contact lenses? If so what type?
Brand of Contact Lens worn?

Other
Please upload a photo of your current contacts.

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Or type in your current contact lens powers, base curves, and diameter.
Please write your contact lens prescription for both eyes (Right and Left)
Are you interested in updating or getting fitted for contact lenses during your upcoming visit?
Do any immediate family members wear glasses or contacts?
If so who?

Other
Feel free to attach any photos/videos related to external eye problems:

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Kindly inform us of any additional concerns, preferences, or special accommodations we should be aware of in preparation for your appointment.
Should be Empty:

Medical History Form