Dr. Priya

Prefix

Ms.
Mrs.
Mr.
Dr.

Name*

First Middle Last

Date of Birth*

Gender

Male
Female

Marital Status

Single
Married
Divorced
Widowed

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone

Mobile Phone

Employer Name

Occupation

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

SSN

Who referred you to our office?

Email

Vision Insurance

None
Advantica
Avesis
Davis
Safeguard
Spectra/Optum
Superior

Medical Insurance

None
Medicare
Full Medicaid
Integral
United Healthcare

Is member same as patient?

Yes
No

Member Name

First Last

Member Date of Birth

Member ID / SSN

Preferred Pharmacy

Pharmacy Address

Street Address City State / Province / Region ZIP / Postal Code

Health History

Height (Ft, Inches)

Weight (lbs)

Blood pressure (if known)

Have you or a family member had any of the following medical conditions?

Diabetes Type I
Diabetes Type II
High Blood Pressure
Heart Disease
Asthma / Lung Disease
Thyroid Disorder
Arthritis
Lupus
Other

Please specify the family member for any conditions marked above.

Have you or a family member had any of the following ocular conditions?

Please specify the family member for any conditions marked above.

Any allergies to medications?

List any medications taken (including aspirin, oral contraceptives, over-the-counter medications and home remedies).

Social History

What hobbies do you enjoy?

Are you pregnant and/or nursing?

Yes
No

How many weeks along are you?

Do you drive?

Yes
No

Do you have visual difficulty while driving?

Yes
No

Please explain.

Do you drink alcohol?

Yes
No

How often?

Social use
1-2 Drinks Daily

Do you use tobacco products?

Yes
No

How often?

Less than 1-2 pk/day
1-2 pk/day
More than 2 pk/day

Do you use recreational drugs?

No
Recreational use
Chemically Dependent
Other

Have you ever had a blood transfusion?

Yes
No

Have you ever been exposed to or infected with Hepatitis A/B/C?

Yes
No

Have you ever been exposed to or infected with HIV?

Yes
No

Have you ever been exposed to or infected with other STDs?

Yes
No