Patient History
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1Social Security No. ___________________
PATIENT HISTORY
COMPLETE BOTH SIDES
PATIENT NAME:________________________________________________________________________
TODAY’S DATE:____________________
First
Middle
Last
DATE OF BIRTH: _______________________
AGE:________
SEX:________
MARITAL STATUS:______________________
RACE: _________________________ ETHNICITY: ____________________________ PREFERRED LANGUAGE: ____________________________
LOCAL ADDRESS: _____________________________________________________________________________________________________________
Street
City
State
Zip Code
HOME PHONE: ____________________________ WORK PHONE: ____________________________ CELL PHONE: _________________________
EMAIL ADDRESS: ______________________________________________________________________________________________________________
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PREFERRED METHOD OF COMMUNICATION:
Home Phone
Work Phone
Cell Phone
Email
Postal
PERSON RESPONSIBLE FOR ACCOUNT (If Different): _____________________________________ Relationship:___________________________
PERMANENT ADDRESS (If Different): ____________________________________________________________________________________________
Street
City
State
Zip Code
IF STUDENT: Grade____________________________ School___________________________________________________________
Occupation_______________________
Employer__________________________ Address ___________________________________
Aproximate date of last exam: ___________________ By: _____________________________ City: _______________________________
Main purpose of visit today: _______________________________________________________________________________________________________
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Do you feel your prescription needs changing at:
DISTANCE:
Yes
No
NEAR:
Yes
No
REFERRED BY: Another Patient (Name)_________________________________________ Newspaper (Name)________________________________
Phone Book___________________________________ Website_______________________________ Other_____________________________________
OCULAR HISTORY: Have you ever had any of the following? (Please check positive responses only):
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Conjunctivitis
Cataracts
Glaucoma
Amplyopia (Lazy Eye)
Macular Degeneration
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Ocular Injury
Visual Loss
Strabismus
Stye
Photophobia
*Describe_________________________________________________________________________________________________________
GENERAL HEALTH: In your past, or present, have you had any of the following? (Please check positive responses only):
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Allergies
Drug Sensitivities
Eye Surgery
Smoker
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Asthma
High Blood Pressure
Eye or Head Injuries
Alcohol Use
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Diabetes
Skin Conditions
Headaches*
Other Substance Use
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__________________________________________
Fainting
Surgical Operations
*When do you get them?
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Hay Fever
Eye Diseases
*Where do they hurt?
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Epilepsy
Nervous System Problems
Respiratory System Problems
FAMILY HISTORY
To date, has anyone in your family had any of the following? (Please check positive responses only and indicate relationship)
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Diabetes
Any Eye Disease
Glaucoma
_______________
________________
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Eye Color:
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Brown
Blue
Green
Hazel
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Heart Disease
Tuberculosis
High Blood Pressure
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________________
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Hobbies:
______________________________________________
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Blindness
Any Vascular Disease
Tumors
______________________________________________
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Are you presently taking any medications including birth control pills? __________ If so, please state which ones and for what purpose:
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
Date of last general health exam: ______________________ Physician: __________________________________ Phone: __________________________
Please state any findings from the exam including pregnancy: ___________________________________________________________________________
________________________________________________________________________________________________________________________________
Do you experience any eye strain, CRT discomfort, i.e. pain of any sort, spots occasionally, twitching eyelids? __________________________________
When? _________________________________________________ How often? _____________________________________________________________
Have you ever worn contact lenses? _________________________ If yes, what type? ________________________________________________________
Who prescribed them? ________________________________________________________ What city? _________________________________________
Do you wear contact lenses now? ___________________________ If not, why did you quit? __________________________________________________
________________________________________________________________________________________________________________________________
When did you stop wearing them? __________________________________________________________________________________________________
What type of contact lenses are you interested in wearing? _____________________________________________________________________________
Receipt of HIPAA Notice of Privacy Practices:
Print Name: _________________________________________________________
Signature: ______________________________________ Date: _______________
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Parent category: Medical