Patient Information and Medical History Form

Patient Information

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

Personal Information

Title	First*	Last*	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev. Fr.

Current Residence

Address		Apt/Suite #
City		State	NC AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY ND OH OK OR PA RI SC SD TN TX UT VT VI VA WA WV WI WY	Zip

Contact Information

Home Phone		Cell Phone*
Email		Preferred Contact By	Cell Phone Home Phone Work Phone Other Phone Text Message Email
DOB (mm/dd/yyyy)		Sex	Female Male
Marital Status	Single Married Separated Divorced Widowed Unknown	Employment Status	Employed FT Student PT Student
Occupation/Grade		Parent/Guardian
Race	American Indian or Alaska Native Asian Black or African American Hispanic or Latino Pacific Islander White Declined to answer	Ethnicity	Hispanic or Latino Non Hispanic or Latino Declined to answer
Preferred Language	English Spanish

Who Referred You to Us?

Billing Information

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Fr.

Address		Apt/Suite#
City		St	NC AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY ND OH OK OR PA RI SC SD TN TX UT VT VI VA WA WV WI WY	Zip
Hm Phone

After completing All Forms, click Submit Data on the Final Tab

Primary Insurance

Insurance

Insurance Name:	None Aetna Avesis Block Vision Blue Cross Blue Shield Cigna Community Care Vision Program Davis Vision Humana Medicare MES National Vision Administrators New Insurance New Insurance Spectera Superior Vision Superior Vision UMR United Health Care Vision Service Plan
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other	Sex:	Male Female

Address:

City:		State:		Zip:
Phone Number:		Birthday:
SSN:		Employer/School:

After completing All Forms, click Submit Data on the Final Tab

Secondary Insurance

Insurance

Insurance Name:	None Aetna Avesis Block Vision Blue Cross Blue Shield Cigna Community Care Vision Program Davis Vision Humana Medicare MES National Vision Administrators New Insurance New Insurance Spectera Superior Vision Superior Vision UMR United Health Care Vision Service Plan
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other	Sex:	Male Female

Address:

City:		State:		Zip:
Phone Number:		Birthday:
SSN:		Employer/School:

After completing All Forms, click Submit Data on the Final Tab

Vision Benefit

Insurance

Insurance Name:	None Aetna Avesis Block Vision Blue Cross Blue Shield Cigna Community Care Vision Program Davis Vision Humana Medicare MES National Vision Administrators New Insurance New Insurance Spectera Superior Vision Superior Vision UMR United Health Care Vision Service Plan
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other	Sex:	Male Female

Address:

City:		State:		Zip:
Phone Number:		Birthday:
SSN:		Employer/School:

After completing All Forms, click Submit Data on the Final Tab

General Medical History

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

Check the box for any conditions that apply:

	You	Mom	Dad	Sib	Describe (type, when were you diagnosed, etc)
Hypertension
Thyroid
Cardiovascular
Cancer
Diabetes

If YOU are diabetic, when were you diagnosed?		Last A1C level?
Are you Pregnant or Nursing?   No Unsure Pregnant Nursing

List ALL major injuries or surgeries you have had and approx dates:

List any other medical conditions you have had, including non-drug allergies:

List all Rx and over-the-counter medications you currently take:

List any vitamins or supplements you currently take:

List any drug allergies you have:

Smoking Status	Never smoker Current some day smoker Current every day smoker Former smoker	Alcohol Use	No Yes Occasionally Socially 1 drink per day Multiple drinks per day
Do you live alone?	No Yes assisted living nursing home

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)

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

Cardiovascular (e.g., chest pain, racing heartbeat, swollen feet/ankles, TIAs)

Respiratory (e.g., chronic cough, shortness of breath, wheezing)

Genital, Kidney, Bladder (e.g., bladder/urinary problems, pain, discharge, menstrual changes, impotence)

Gastrointestinal (e.g., constipation, diarrhea, gastric reflux (GERD), jaundice, nausea, vomiting)

Endocrine (e.g., heat or cold intolerance, thinning hair, excess thirst, excess urination)

Muscles, Bones, Joints (e.g., pain, stiffness, swelling, weakness, limited movements)

Skin (e.g., dry, itchy, flaky, rash, growths, bumps, redness, discoloration)

Neurological (e.g., headaches, numbness/tingling, tremors, poor balance, dementia, speech problems)

Psychiatric (e.g., depression, anxiety, sleep problems, paranoia, obsessive/compulsive)

Blood/Lymph (e.g., anemia, bleeding gums, delayed clotting, unexplained bruising)

Allergy/Immune (e.g., swollen lymph nodes, itching, sneezing, runny nose/eyes)

Ocular History

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

Check the box for any conditions that apply:

	You	Mom	Dad	Sib	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:

List any other significant eye problems you have had:

List all Rx and over-the-counter eye medications you currently use:

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?
If you are having complaints with computer work, how far is the monitor from your eyes?
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?

After completing All Forms, click Submit Data on the Final Tab

Submit / Signatures

Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below.

Office Policies

View Office Policy Form

Patient Name:

Thank you for choosing us for your eye care needs. Please do not hesitate to ask any of our staff members for additional questions. I have read and agreed to all terms listed above, that I, or my dependents, will receive.

Signature: Date:

Screening Sheet

View Screening Sheet Form

Our Doctors strongly recommend having both screening tests performed. If you are uncertain about which options to select, our staff will explain and help you select the best option for you. During your visit, dilation drops could be instilled when our Doctor deemed necessary. Your vision will be blurry at near for approximately 5-6 hours and more sensitive to light then normal. Your office visit could go from routine to medical office visit based on the findings. I have read and reviewed this form.

Signature: Date:

You're Done! Please hit the Submit button below.