Dr. Veda Szeto Optometry Patient Form

Dr. Veda Szeto Optometry

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Today's Date

IMPORTANT: This questionnaire is to be reviewed at each appointment. Please answer all questions.

Name

First Middle Last

Address

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

Social Security #

Work Phone

Mobile Phone

Date of Birth

Occupation

Employer

Emergency Contact*

First Last

Phone

Date of last eye exam

Dilated?

Yes
No

Referred by

Primary Vision Coverage

Secondary Coverage

Medical Information

How is your general health?

Do you take medication for any of these systems?

Please check all that apply.

Please explain

Diabetes?

Yes
No

Type

Date of diagnosis

Allergies to medication?

Yes
No

Which?

Reactions?

Family History

High blood pressure

Yes
No

Relation

Macular degeneration

Yes
No

Relation

Diabetes

Yes
No

Relation

Retinal detachment

Yes
No

Relation

Glaucoma

Yes
No

Relation

Cataracts

Yes
No

Relation

Personal Eye Information

Do you have any eye conditions or problems?

Yes
No

What kind?

Have you had any eye operations?

Yes
No

Type

Date

Have you had an eye injury?

Yes
No

Kind

Date

Do you have any of the following?

Glaucoma
Macular degeneration
Cataracts
Dry eyes
Retinal detachment
Blurred vision

Do you wear glasses?

Yes
No

Contact lenses?

Yes
No

Type

Additional information

Doctor use only

Reviewed by

No change

Date

Reviewed by

No change

Date

Reviewed by

No change

Date

Signature

I understand my right to privacy under HIPAA.

Signature

I have read and understand your office policies.