Patient History Form


New and Established Patients:
 Please fill in as much as possible to the best of your knowledge. The most important section is the "Medical History" tab which will save you 10-15 minutes during your office visit. These forms are optimized for use on a desktop but are still able to be completed via mobile phones. ***Your progress will be saved as you move through the tabs but will not be uploaded to your account until you click the large green "Submit" button on the final tab, "Medical history".*** If you have questions, please reach out to a staff member.

Demographics

Title *First *Last MI Suffix Nickname
Address:
City: State/ZipCode
*Home Phone: Work Phone:
Other Phone:
*Cell Phone: Preferred Contact Method:
SSN *Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Misc/Guardian How did you hear about us?
Billing Information Is The Billing Address Different?
Title First Last MI Suffix
Address

City State ZipCode
Home Phone:
Work Phone:

Medical History

To save time during your exam, please fill out as much information as possible. Thank you.


CHIEF CONCERN
No vision correctionWears glasses Wears contact lenses
How did you hear about our office?

PAST OCULAR HISTORY
GlaucomaMacula/Retinal DiseaseCataracts
KeratoconusOther ocular disease
Previous ocular surgeries, injuries, or infections

PAST MEDICAL HISTORY
DiabetesHigh blood pressureCardiovascular diseaseRespiratory DiseaseHigh CholesterolThyroid Disease
Other disease

CURRENT MEDICATIONS No current Meds
Vitamins
Over the counter drugs

Allergies NKDA


Family Medical History (Please list condition and who)
Family Ocular History (Please list condition and who)

Name of Family Physician Date of Last Exam
Name of Last Eye Doctor Date of Last Eye Exam

Other information

CONTACT LENSES
Interested in a contact lens exam?Currently wear contact lenses?Soft ContactsRigid Gas Perm Lenses

Brand Name Right Eye Base Curve Power
Brand Name Left Eye Base Curve Power
# Hours worn each day
How often do you throw away the contacts?
How often are you supposed to throw them away?
Do you sleep in your contacts?


SOCIAL HISTORY
Occupation: Hobbies STD
Smoking Status: Type: How Long:
Alcohol: Type: How Long:
Illegal Drugs: Type: How Long:


These questions are solely asked to meet the Government Meaningful Use criteria for electronic medical records and will be used for no other purpose.

Height Feet: Inches: Weight: Preferred Language : Race: Ethnicity:


OFFICE POLICIES
By checking this box, I allow Premier Eyecare of Arizona to file medical or vision insurance claims on my behalf.
By checking this box, I acknowledge that I will be financially responsible for any balance not paid by my insurance. I also acknowledge that custom eyewear is nonrefundable.
By checking this box, I acknowledge that I have read a copy of the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I have read a copy of the Notice of Privacy Practices and Patient Consent Form. Checking this box allows Premier Eyecare of Arizona to conduct normal office procedures in accordance with HIPAA.

I have read a copy of the Notice of Privacy Practices and Patient Consent Form.
This allows Premier Eyecare of Arizona to conduct normal office procedures in accordance with HIPAA and file insurance claims on my behalf.
I acknowledge that I will be financially responsible for any balance not paid by my insurance.

SIGNATURE / TYPE YOUR NAME Date

Submit Data

Please click the "SUBMIT DATA" button and your information will be electronically sent to our office. Thank you.