Patient Information and Medical History Form

Thank you for using our secure online forms. 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 (310) 541-3411. 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)

Title	First*	Last*	MI	Suffix	Nickname

Address

City	St	Zip

Hm Phone*
Cell Phone*
Wk Phone
Other 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

Whom may we thank for referring you to our office?

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix

Address

City	St	Zip
Hm Phone
Wk Phone

Ocular History * If a question does not apply to you, please leave it blank. *

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 approximate 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 difficulties 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, dryness, 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 difficulties 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 glasses?
Are you interested in contacts?
Are you interested in more information about LASIK?
Contact Lens Wearers Only
What disinfecting solution do you use?
How long do you usually wear your lenses each day?
How often do you replace your lenses?
How old is your current pair of contacts?

General Medical History * If a question does not apply to you, please leave it blank. *

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
Elevated Cholesterol
Thyroid
Cardiovascular
Cancer
Diabetes

If *YOU* are diabetic, what year were you diagnosed?		Last A1C level?
Are you Pregnant or Nursing?

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

List any other medical conditions you have had:

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

List any vitamins or supplements you currently take:

List any drug or environmental allergies you have:

Smoking Status
Alcohol Use
Do you live alone?

Review of Systems * If a question does not apply to you, please leave it blank. *

(We're sorry you have to fill this out, but these are required questions and do help us take the best care of your ocular health.)

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, menopause, 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)

If you currently wear glasses please bring them into your appointment, or if you wear contact lenses please wear them at least 1 hour before your appointment time. Thank you!

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Patient Information and Medical History Form