New Patient Health History Form
Name
Legal First Name
Last Name
Nickname:
M:
DOB:
-
Month
-
Day
Year
Date
M or F SSN:
Marital Status
Married
Single
Divorced
Widowed
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone:
Please enter a valid phone number.
Work Phone:
Please enter a valid phone number.
Cell Phone:
Please enter a valid phone number.
Email Address:
example@example.com
Sports/Hobbies:
Preferred Method of Contact:
Email
Texting Preferred
Cell Phone
Home Phone
Work Phone
Employer/School:
Occupation/School Grade:
Emergency Contact:
Relation:
Phone Number:
Please enter a valid phone number.
How did you hear about our office?
Height:
Type a label
feet
Type a label
inch
Weight:
Date of Last Medical Exam:
-
Month
-
Day
Year
Date
Date of Last Eye Exam:
-
Month
-
Day
Year
Date
Eye Doctor:
Pharmacy:
Primary Physician/Clinic:
Medical History:
Yes
No
Cancer
Sinus/Congestion
Stroke
Heart Disease
Heart Cholesterol
High Blood Pressure
Asthma
Bronchitis
Emphysema
Kidney Problems
Arthritis
Crohn's Disease
Rosacea
Eczema
Multiple Sclerosis
Migraines
Seizures
ADHD
Anxiety
Depression
Thyroid Disease (Hyper/Hypo)
Anemia
Diabetes
Blood Sugar
Taken
AIC
Taken
Family History:
None
Mother
Father
Grandfather
Unknown
Diabetes
High Blood Pressure
High Cholesterol
Thyroid Disease
Heart Disease
Cancer
Glaucoma
Cataracts
Macular Degen
Retinal Detach
Crossed Lazy/Eyes
Tetanus shot in last 10 years?
Yes
No
Are you currently pregnant or nursing?
Yes
No
Alcohol use?
Yes
No
Amount
Tobacco use?
Yes
No
Amount
Medications:
Allergies(to medications and/or seasonal):
Surgeries in the last 10 years:
Insurance Authorization/HIPAA Notice
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: