Eye Care Family Vision Center Patient Form

Date*

Name*

First Last

Gender

Male
Female
Prefer Not to Answer

Date of Birth*

Address*

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

Cell Phone*

Secondary Phone

Email*

Employer

Occupation

What is the reason for today's exam?

Insurance Information

Primary Health Insurance

Name of Insured

First Last

Insured ID#

Vision Insurance

Name of Insured

First Last

Insured ID#

Insured Date of Birth

Relationship to Patient

Medical and Ocular History

Date of Last Eye Exam

From Dr.

Current medications (Rx or OTC) (List name of medications including eye drops, vitamins, & birth control pills)

Allergies to medications?

Yes
No

If yes, list them here

Please list any surgeries and dates if applicable

Do you use cigarettes/tobacco?

Yes
No

If yes, how often?

Do you use alcohol?

Yes
No

General Health

Diabetes

Yes
No
In Family

High Blood Pressures

Yes
No
In Family

Heart Disease

Yes
No
In Family

Headache

Yes
No
In Family

Thyroid

Yes
No
In Family

Arthritis

Yes
No
In Family

Cancer

Yes
No
In Family

Allergy/Sinus

Yes
No
In Family

Other

Eye History

Glaucoma

Yes
No
In Family

Macular Degeneration

Yes
No
In Family

Cataracts

Yes
No
In Family

Retinal Detachment

Yes
No
In Family

Lazy Eye

Yes
No
In Family

Eye Surgery

Yes
No
In Family

Eye Injury

Yes
No
In Family

Color Blindness

Yes
No
In Family

Other

Patient Name*

First Last

Patient/Guardian Signature*

Date*