Fruitvale Optometry

Name*

First Last

Date of Birth*

Gender

Male
Female

Address

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

Email

Cell Phone

Home Phone

Work Phone

Occupation

Insurance

Policy Holder's Name

Social Security Number

Emergency Contact

Emergency Contact Phone Number

Primary reason for today's visit?

Which eye?

Left
Right
Both

How long?

When does it happen?

What makes it worse or better?

Severity?

How did you find our office? Please check one.

Who referred you?

Medical History

Primary Care Physician

Date of Last Eye Exam

List drug allergies:

List eye medications:

List other medications:

Do you wear:

Glasses
Soft Contacts
Hard Contacts
I'm interested in a contact lens fitting

Check any of the following conditions that apply to you:

What year were you diagnosed?

Recent blood glucose levels?

Has anyone in your family ever had any of the following?

Lazy eye
Glaucoma
Macula Degeneration
Retinal detachment

Social History

Race:

Ethnicity:

About how many hours a day do you spend using a computer or tablet?

Do you smoke?

Yes
No
Occasionally

Alcohol use:

Frequent
Sometimes
Seldom
Never

Illegal drug use:

Frequest
Sometimes
Seldom
Never

Do you currently, or have you ever had any problems in the following areas:

Describe:

Acknowledgement

I acknowledge that a copy of Fruitvale Optometry’s HIPPA policy is available upon request. I certify that the information above is correct to the best of my knowledge. I authorize my insurance to pay Fruitvale Optometry directly for services received here. I understand that the description of insurance benefits doesn’t guarantee payment and I accept responsibility for all charges that my insurance doesn’t cover plus any charges necessary to collect debts owed.

Signature of patient (Parent/Guardian if minor)