Patient Information Form "*" indicates required fields Thank you for choosing us for your eye care needs. We are delighted to have you as a patient, and appreciate the confidence you have placed in us. Please take a moment to fill out your information as accurately as possible. This information will be kept confidential.Patient InformationName* First Middle Last Gender* Female Male Date of Birth* MM slash DD slash YYYY Salutation Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix Name PreferenceEmail AddressAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Cell PhoneWork PhoneHome PhoneSocial Security Number (last 4 digits)Driver License NumberEmployerPerson Responsible for PaymentRelationship to PatientYour OccupationHow Did You Hear About Us?Select Referral Type >Friend or FamilyInsuranceGoogleYelpFacebookWalk-InOtherWho May We Thank for Referring You?Have We Seen Any Members of Your Family? Yes No If Yes, Who?Name of Last Eye Doctor Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Suffix Date of Last Eye ExamName of Primary Care Doctor Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Suffix Date of Last Physical ExamOcular HistoryDo You Wear Glasses? Yes No How often do you wear them? Always Occasionally Work Reading Only Driving Only Do You Wear Contact Lenses? Yes No Type Soft Gas Permeable BrandContact Lens Replacement Schedule Daily 2 Weeks Monthly Quarterly Yearly Have You Had LASIK/PRK? Yes No When?Are you interested in LASIK or other refractive surgery? Yes No Have You Ever Had Any Eye Injuries? Yes No Please describe and indicate which eye:Have You Ever Had Any Eye Surgeries? Yes No Please describe and indicate which eye:Have You Ever Been Diagnosed With The Following? Cataract Glaucoma Macular Degeneration Diabetic Retinopathy None Please Mark Any Conditions That Apply To You Blurred Far Vision Blurred Near Vision Poor Night Vision Double Vision Dry Eyes Watery Eyes Itchy Eyes Floaters or Spots See Flashes Loss of Vision Light Sensitive Headaches Eye Strain Eye Turn Eye Pain or Discomfort Family HistoryHas Anyone In Your Family Been Diagnosed With The Following? Blindness Cataract Glaucoma Macular Degeneration Retinal Detachment Strabismus (Eye Turn) Hypertension Diabetes Cancer Heart Disease Thyroid Disease Other Who?Who?Who?Who?Who?Who?Who?Who?Who?Who?Who?Who?Personal Medical HistoryPlease check if any of the following applies to you, and list any medication for each condition. If you have none of these conditions, then please check none.Allergies None Medication Allergies Environmental Allergies List All AllergiesCardiovascular None Arrhythmia High Cholesterol Heart Disease Hypertension Stroke Other Other:Constitutional None Dizziness Fever Nausea Other Other:Endocrine None Crohn's Disease Type 1 Diabetes Type 2 Diabetes Thyroid Disorder Other Other:Gastrointestinal None Colon Cancer Colitis Gallstones Hepatitis Gastroesophageal Reflux Other Other:Genitourinary None Kidney Stones Prostate Cancer STDs Uterine Cancer Urinary Infections Other Other:Head/ENT None Dry Mouth Sinusitis Hearing Loss Ears Ringing Other Other:Hematological None Anemia Breast Cancer Leukemia Sickle Cell Disease Other Other:Immunological None HIV Sarcoidosis Sjogren's Syndrome Lupus Other Other:Integumentary (Skin) None Acne Rosacea Psoriasis Eczema Skin Cancer Other Other:Musculoskeletal None Ankylosing Spondylitis Arthritis Rheumatoid Arthritis Osteoporosis Scoliosis Other Other:Neurological None Bell's Palsy Brain Tumor Migraines Multiple Sclerosis Myasthenia Gravis Other Other:Psychiatric None Attention Disorder Anxiety Disorder Autism Bipolar Disorder Depression Other Other:Respiratory None Asthma Bronchitis COPD Emphysema Lung Cancer Other Other:Alcohol Use Yes No Tobacco Use Yes No Recreational Drug Use Yes No Please list all current medications including non-prescription and birth control.Primary InsurancePlease bring all insurance cards with you to your appointment.Name of Vision InsurancePrimary's Social Security NumberPolicy NumberPrimary's Name First Middle Last Primary's Date of Birth MM slash DD slash YYYY Marital Status Single Married Other Name of Medical InsurancePolicy NumberGroup NumberPrimary's Name First Middle Last Primary's Date of Birth MM slash DD slash YYYY Secondary InsuranceDo you have secondary insurance? Yes No If you have coverage through another plan/organization, please fill in the details below.Insurance Company NamePrimary's Social Security NumberPrimary's Name First Middle Last Primary's Date of Birth MM slash DD slash YYYY Policy NumberGroup NumberLet Us Know Your ActivitiesPlease Check Each Activity in Which You Participate Aerobics Arts & Crafts Baseball Basketball Boating Bowling Camping Computers/Video Games Cycling Dance Fishing Football/Rugby Gardening Golf Hunting Martial Arts Metal Working Movies Music Racquetball Reading Soccer Sewing Snow Skiing Swimming Television Tennis Volleyball Water Skiing Weight Training Other Other ActivitiesCommentsIf you have any comments you would like to add, please enter them here.CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Δ
