Patient Form

Name*

Address*

Email Address

Gender*

Date of Birth*

Social Security Number (last 4 digits only!)

Preferred Language*

Race*

Ethnicity*

Marital Status​​​​​​​

Employment Status

Employer

Occupation

How were you referred to our office?

Communication Preference

Eye History

Please check off any current conditions you suffer from

Glasses History

Do you wear glasses?*

Contact Lens History

Do you wear contact lenses?

Medical History

When, approximately, was your last eye exam?

Where did you get your last eye exam?

When, approximately, was your last physical exam?

Who is your primary care physician?

Do you drink alcohol?

Do you smoke?

Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)

Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)

Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)

Please list all hospital surgeries you have ever had:

Please list all prescription and over-the-counter medications you take and for what conditions

Please list all drug allergies you have

Please check off any current conditions you suffer from

Primary Insurance

Please bring all insurance cards with you to your appointment.

Insurance Company Name

Insurance Company Phone Number

Address

Insured's Name

Identification Number

Group Number

Insured's Date of Birth

Patient's Relation to Insured

Secondary Insurance

Do you have secondary insurance?

Comments

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