Patient Information and Medical History

Patient Information

First Name*

Middle Initial

Last Name*

Nickname

Birth Date (mm/dd/yyyy)*

Street Address

Unit Number:

City

State

Zip Code

Gender Female Male

Marital Status

SSN

E-mail*

Home Phone

Work Phone

Cell Phone

Which number do you prefer we call during normal business hours?

Preferred Language

Advanced Directives - If you have a DNR, please bring a copy to your appointment or email it to This email address is being protected from spambots. You need JavaScript enabled to view it.

Do you have a living will? Yes No

Do you have an advanced directive – DNR (Do Not Resuscitate)? Yes No

Privacy Regulations - Due to privacy regulations, please indicate below anyone that you want to allow to inquire about your medical status.
*I authorize the following person(s) to communicate with your office regarding my care:

Name/Relationship

Phone Number

Your Initial

Name/Relationship

Phone Number

Your Initial

Emergency Contact

Emergency Contact Name*

Relationship

Phone

Alternate Phone

Employment Information

Employment Status Full-time
Part-time
Retired
Active Duty

Employer

Occupation

Are you a human?

Referral Information

Person who referred me to this practice

Healthcare Providers

Optometrist

Located at

Primary care physician*

Phone

Name of Insurance Company or Health Benefit Plan

Insurance ID Number

Primary Insurance

Policy Holder Name

Policy Holder's Birth Date (mm/dd/yyyy)

Relationship to Patient

Secondary Insurance

Policy Holder Name

Policy Holder's Birth Date (mm/dd/yyyy)

Relationship to Patient

Tertiary

Policy Holder Name

Policy Holder's Birth Date (mm/dd/yyyy)

Relationship to Patient

Supplement Insurance ID #?

Upload photo of Insurance Card - Click on Folder to Upload - Please include a front and back photo of your card.

Medical History

Environmental Allergies
Anemia
Anxiety
Arthritis
Asthma
Back Problems
Bleeding Disorder
Cholesterol Disorder
Cancer
Chest Pain
Depression
Diabetes
Frequent Headaches
Fuch’s Dystrophy
Glandular/hormone problem
Hearing Problem
Deaf
Heart Disease/Pacemaker
Heart Murmur
Hepatitis
HIV
High Blood Pressure
Joint Pain
Kidney Disorder
Lung Disease
Lupus
Melanoma
Memory Problem
Numbness/tingling
Osteoporosis/Osteopenia
Prostate Disorder
Recent Weight Change
Sarcoidosis
Seizures
Shortness of breath
Sjogrens Syndrome
Stomach / Digestive Issues
Stroke
Thyroid Disorder
Vertigo / Dizziness
Other
N/A
Please specify other

Social History

Alcohol Use*

Number of Glasses Daily

Tobacco Use*

Drug Use

Past Medical Surgery

Type of Surgery

Date of Procedure

Type of Surgery

Date of Procedure

Past Eye Surgery, Disease or Injury

Type of Surgery

Date of Procedure

Type of Surgery

Date of Procedure

Type of Surgery

Date of Procedure

Family Members Eye Medical History

Eye Disease

Relationship

Eye Disease

Relationship

Eye Disease

Relationship

Your Vision and Eye History

Glasses*

# of Years

Contact lenses*

# of Years

Mono-Vision Contacts*

# of Years

Lasik*

# of Years

Prescription Medication Information Sheet

Medicine Name*

Daily Dosage (mg., ml.)*

Reason for taking*

Medicine Name

Daily Dosage (mg., ml.)

Reason for taking

Medicine Name

Daily Dosage (mg., ml.)

Reason for taking

Additional space if needed

Eye Medication List

Eye Drop

Reason for taking

# of times per Day

Which Eye

Eye Drop

Reason for taking

# of times per Day

Which Eye

Additional space if needed

Preferred Pharmacy Refill Location

Pharmacy Name*

Pharmacy Location*

Pharmacy Phone*

Pharmacy Fax

Drug Allergies

Allergy*

Reaction*

Allergy

Reaction

Allergy

Reaction

Additional space if needed

List of Other Physicians/Specialists involved in your care

Physician Name

Specialty Type

Phone#

Physician Name

Specialty Type

Phone#

Additional space if needed

Verification

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Patient Testimonials

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