Welcome To Our Office!

Please complete the following form as thoroughly as possible. The information in this confidential case history form is critical to the evaluation of your vision and health.

Date

Patient Information

Name

First Last

Address

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

Home Phone

Work Phone

Cell Phone

Email

How do you prefer to be contacted?

Home #
Work #
Cell #
Text
Email

Patient's SSN

Date of Birth

Age

Sex

M
F

Employer (or School)

Occupation (or Grade)

Spouse (or Parent's Name)

Spouse (or Parent's Work)

How did you first hear about our office?

Friend or Relative
Another Doctor
Insurance List
Saw Sign/Building
Facebook
Online Search
Instagram
Neighborhood Webpage

If you answered "Friend or Relative" for the question above, whom may we thank for the referral?

Insurance Information

Vision Insurance

Subscriber Name

Subscriber SSN/ID#

Subscriber Birth Date

Primary Medical Insurance

Subscriber Name

Subscriber SSN/ID#

Subscriber Birth Date

Secondary Medical Insurance

Subscriber Name

Subscriber SSN/ID#

Subscriber Birth Date

Do you participate in a flex spending account?

Yes
No

Lifestyle Questions

Do you... (check all that apply)

...use digital devices on a regular basis? If yes, how many hours per day? (please answer below)
...think you might benefit from thinner, lighter lenses?
...prefer NOT to wear glasses at times?
...spend time outdoors? How often? (please answer hrs/week below)
...participate in vision-related sports or other activities?

If yes to the above questions, please specify:

Section Break

Date of Last Eye Exam?

By Whom?

Have you had any eye-related surgeries of any kind?

Yes
No

If you answered "yes" to the question above, please list:

Have you ever experienced, been diagnosed, or treated for any of the following?

Other eye disorders:

Patient Medical History

Name of Family Physician

Address

Date of Last Physical Check-Up

Height

Weight

Females: Are you pregnant or nursing?

Yes
No

Current Medications (Rx or Over-The-Counter)

List name of medications including eye drops, vitamins, & birth control pills: dosages and frequency

List any non-eye related surgeries or hospitalizations

Are you allergic to any medications?

Yes
No

If so, what medications?

Do you use cigarettes/tobacco?

Yes
No

Alcohol?

Yes
No

Other substances?

Yes
No

Have you ever been diagnosed or treated for the following health problems? (Check all that apply)

Do you have a family medical history of any of the following? (Check all that Apply)

Please indicate mother or father's side for the items selected above:

Eyes on Cypress

Welcome To Our Office!

Please complete the following form as thoroughly as possible. The information in this confidential case history form is critical to the evaluation of your vision and health.

Patient Information

Insurance Information

Lifestyle Questions

Section Break

Patient Medical History