Patient Information and Medical History Form

Thank you for using our secure online forms. Please fill out as much information as you can, but leave blank any fields that don't apply to you. When you are finished, be sure to hit the submit button at the bottom of the form and close the browser window to ensure privacy of your data. If you have any questions, please call us at (503) 444-7639. 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*
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
How did you hear about our office?
Please Specify
Newsletter options

Billing Information

Click this box if billing address is the same as above.

TitleFirstLastMISuffix
Address
City St  Zip
Hm Phone  
Wk Phone

Vision Insurance Plan

Plan Information
Vision Insurance Plan Name:
Insurance ID (or last 4 of SS# if none):
Insurance Policy Group:
Check this box and fill out info below if patient is not primary member on account:
Primary member on account
Name: Last, First MI
Relationship to Insured: Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
Employer/School:

Primary Medical Insurance

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Check this box and fill out info below if patient is not primary member on account:
Primary on Account
Name: Last, First MI
Relationship to Insured: Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
Employer/School:

Secondary Medical Insurance

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Check this box and fill out info below if patient is not primary member on account:
Primary on Account
Name: Last, First MI
Relationship to Insured: Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
Employer/School:

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?  
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 eye medications you currently use:
List all other 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
Alcohol Use

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 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
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?

Privacy Policy & Consent to Treat
By checking here I hereby give my permission to Portland Eye Care to treat above named Patient and also accept any and all financial responsibilities for services provided.
By checking here, I hereby request that payment under my insurance program(s) be made direct to Portland Eye Care for any services furnished to me. I authorize Portland Eye Care to release any information necessary to process claims. I understand any non-reimbursed charges will become payable by myself.
By checking here I acknowledge that the Notice of Privacy Practices is available at eyepdx.com/notice-of-privacy-practices, and that I have read and understood the notice. I further acknowledge that I have the right to request a copy of the notice and one will be provided.
Please type your name here as your digital signature:

Please click the Submit button to finish.