Patient Information and Medical History Form

Thank you for using our secure online form. Please fill out as much information as you can. When you are finished be sure to hit the submit button at the bottom of the form. If you have any questions, please call us at 702-876-2020 for the Sahara Location. We can always change the data in the office if you are unsure about what to enter in any of the fields.

Patient Information

*Required (first and last name and either a home OR cell phone)

TitleFirst*Last*MISuffixNickname
Address  
City St  Zip
Hm Phone*
Cell Phone*
Email
Preferred Contact By
DOB (mm/dd/yyyy)  
Sex Female Male
Marital Status
Employment Status Employed FT Student PT Student
Occupation/Grade
Employer/School
Parent/Guardian
Race
Ethnicity
Preferred Language

Who may we thank for referring you to our office?  

Billing Information

Is The Billing Address the Same?

TitleFirstLastMISuffix
Address
City St  Zip
Hm Phone  
Wk Phone

General Medical History

Primary physician's name and phone  
When was your last physical exam?

Check the box for any conditions that apply:

You Family No Describe (type, when diagnosed,treatment,etc)
Diabetes
Hypertension
Thyroid
Cardiovascular
Cancer
If YOU are diabetic, when were you diagnosed?    Last A1C level? 
Average Blood Sugar


Are you Pregnant or Nursing?
 
 
List ALL major injuries or surgeries you have had and approx dates:
Check for None
List any other medical conditions you have had, including non-drug allergies:
Check for None
List all Rx and over-the-counter medications you currently take:
Check for None
List any vitamins or supplements you currently take:
Check for None
List any drug allergies you have:
Check for None
Smoking Status
Alcohol Use
Do you live alone?  

 

Review of Systems
Please list any problems you are currently having anywhere, from head to toe:

General (e.g., fever, fatigue, loss of appetite, unexplained weight loss/gain)

Check for None

Ear, Nose, Throat (e.g., sinus/nasal congestion, nose bleeds, dry mouth/throat, sleep apnea, hearing problems)

Check for None
Cardiovascular (e.g., chest pain, racing heartbeat, swollen feet/ankles, TIAs)

Check for None
Respiratory (e.g., chronic cough, shortness of breath, wheezing)

Check for None
Genital, Kidney, Bladder (e.g., bladder/urinary problems, pain, discharge, menstrual changes, impotence)

Check for None
Gastrointestinal (e.g., constipation, diarrhea, gastric reflux (GERD), jaundice, nausea, vomiting)

Check for None
Endocrine (e.g., heat or cold intolerance, thinning hair, excess thirst, excess urination)

Check for None
Muscles, Bones, Joints (e.g., pain, stiffness, swelling, weakness, limited movements)

Check for None
Skin (e.g., dry, itchy, flaky, rash, growths, bumps, redness, discoloration)

Check for None
Neurological (e.g., headaches, numbness/tingling, tremors, poor balance, dementia, speech problems)

Check for None
Psychiatric (e.g., depression, anxiety, sleep problems, paranoia, obsessive/compulsive)

Check for None
Blood/Lymph (e.g., anemia, bleeding gums, delayed clotting, unexplained bruising)

Check for None
Allergy/Immune (e.g., swollen lymph nodes, itching, sneezing, runny nose/eyes)

Check for None

Ocular History

Who was your previous eye doctor?  
When was your last eye exam?

Check the box for any conditions that apply:

You Family No Describe (type, when diagnosed, which eye(s), treatment,etc)
Glaucoma
Macular Degeneration
Retinal problems
Cataracts
Lazy Eye/Eye Turn
List any major eye injuries, infections or surgeries and approx dates:
Check for None
List any other significant eye problems you have had:
Check for None
List all Rx and over-the-counter eye medications you currently use:
Check for None
List any vision complaints you are currently having such as:
  • blurred vision, headaches, eyestrain, double vision, or losing your place when reading
  • itching, burning, redness, pain, sensitivity to light, watering, crusting or mucus discharge
  • seeing rainbows around white lights at night, flashes of light or dark spots/squiggles/webs
How many hours/day do you typically spend using a computer or other digital devices?
How many hours/day do you spend driving?
How many hours/day do you typically spend reading books, magazines, etc?
What are your hobbies/sports activities?
Do you have sunglasses?
Do you have back-up glassess?
Are you interested in contacts?
Contact Lens Wearers Only
What disinfecting solution do you use?
How long do you usually wear your lenses?
How often do you replace your lenses?
How old is your current pair of contacts?

You're Done! Please hit the Submit button.