Patient Information and Medical History Form

Thank you for using our secure online forms. Please fill out as much information as you can. Note that the available options for marital status, race and ethnicity are the options required by the US Government. They also include Latino/Hispanic heritage under ethnicity and consider it independent of race.

When you are finished be sure to hit the submit button at the bottom of the form. If you have any questions, please call the office. 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
Mr. Mrs. Ms. Dr. Rev. Fr.

Address
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*
Cell Phone*
Wk Phone
Other 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	Never Married Married Domestic partner Polygamous Divorced Annulled Legally Separated Widowed
Employment Status	Employed Full Time Student Part Time Student
Occupation/Grade
Employer/School
Parent/Guardian
Race	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Patient Declined to Specify
Ethnicity	Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify
Preferred Language	English Spanish French Chinese Arabic Russian Patient Declined to Specify

Who may we thank for referring you to our office?  

Billing Information

Is The Billing Address the Same?

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

Address
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
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 to you, your parents or siblings:

	No	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?

Height

ft

in

Weight

lbs

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 (<100 cigs equiv) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Current every day smoker Unknown if ever smoked
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:

	No	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 glasses?
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?

Please Note:
Your eyes will be dilated during your appointment.
Mall Vision Center does not accept personal/business checks.
Office policy is to call two days prior to your appointment to confirm. Unconfirmed appointments can be scheduled over if warranted.
Thank you and we look forward to seeing you.

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

Please note that your eyes will be dilated during your appointment.