Patient History Form

Patient History Form

Please fill out the form below to better prepare us when you arrive for your appointment:

General Information
  1. (required)
  2. (required)
  3. (required)
  6. (required)
  7. (required)
  8. (required)
  9. (required)
  12. (valid email required)
Insurance Information
  7. (Please present both cards for copying at the time of your appointment.)
Medical Information
  7. Are you pregnant or nursing?
Vision Information
  1. (required)
  3. Do you where eyeglasses?
  7. Do you where contact lenses?
  13. Do you sleep with your contact lenses on?
  17. Have you had refractive surgery?
  22. Chief Complaint - How can we help you?
  23. Briefly tell us any symptoms you may be experiencing. Your medical insurance may cover this exam if there is a medical reason for your visit such as vision loss, headaches, eye redness, eye pain, eye itching or burning, glaucoma, cataracts, floaters, or dry eyes.
  25. Are you thinking of new glasses today?
  28. Are you thinking of new contact lenses today?
Current Illness / Symptoms
  1. Please answer the following about the compaints and/or symptoms you listed above.
  6. Modifying Factors (is the problem worse at a specific distance or during a specific activity?)
  8. Duration (do the symptoms come and go or are they constant?)
  10. Timing (how long have you noticed this problem?)
  12. Associated symptoms (are you having other problems associated with your symptoms?)
  14. Interventions (does anything seem to help?)
  16. Do you have any family members with a serious disease or problem related to their eyes?
  17. Do you smoke or use tobacco?
  21. Do you use recreational drugs?
  24. Do you use alcohol?
  28. Have you been exposed to any of the following?
Do you have problems with any of the following?
  1. Allergic / Immunologic
  4. Constitutional Symptoms
  7. Cardiovascular
  11. Ear, Nose, Mouth, Throat
  16. Endocrine
  19. Gastrointestinal
  22. Genitourinary
  26. Hematologic/Lymphatic
  29. Integumentary
  32. Musculosketal
  35. Neurological
  38. Psychiatric
  42. Repiratory
 

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