Grand Island Optical Patient History Form

Grand Island Optical Patient History Formadmin2017-08-06T22:19:01+00:00

Grand Island Optical Patient History Form

Date:
Date Format: MM slash DD slash YYYY
SS#:
Date of Birth:
Date Format: MM slash DD slash YYYY
- Mr
- Mstr.
- Miss
- Mrs.
- Ms
- Single
- Married
- Separated
- Divorced
- Widowed
Name:
First Middle Last
Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone #:
Cell #:
Email Address:
Current Occupation:
Employer:
How did you hear about our office?
Health Insurance Name:
Health Insurance Identification Number:
Health Insurance Subscriber's Name:
Vision Insurance Name:
Vision Insurance Identification Number:
Vision Insurance Subscriber's Name:
Health Insurance Subscriber Information (if different from patient)
Name
First Last
DOB:
Date Format: MM slash DD slash YYYY
SS#:
Person responsible for payment:
Relationship to patient:
Address (if different):
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Reason for Visit:
- Eye Infection or Problem
- New Patient Vision Exam
- Established Patient Eye Exam
- Contact Lens Exam
- Contact Lens Follow-up
- Other (Please specify below)
Additional Information:
Do you wear Glasses?
- Yes
- No
Please check all that apply:
- Always
- Only while driving
- For reading
- Sunglasses
- Computer
Do you wear Contact Lenses?
- Yes
- No
If Yes, what type of Contact Lenses?
- Disposable Soft
- Regular Soft
- Gas Permeable
- Other (Please specify below)
Additional Information:
Have you ever had eye surgery?
- Yes
- No
Date of Surgery:
Date Format: MM slash DD slash YYYY
Type of Surgery:
How many hours per day do you use a computer?
- 0-2
- 2-4
- 4-6
- 6-8
- 8+
Are you experiencing any of the following?
Please check all that apply:
- Blurred Distance Vision
- Blurred Near Vision
- Burning Eyes
- Double Vision
- Dry Eyes
- Eye Strain
- Flashes of Light
- Gritty Feeling Eyes
- Headaches
- Itchy Eyes
- Loss of Vision
- Night Vision Problems
- Objects Floating in Vision
- Pain in Eyes
- Red Eyes
- Sensitivity to Light
- Watery Eyes
Name of Family Doctor:
Are you currently under the care of a physician?
- Yes
- No
If yes, please list reasons:
Are you Pregnant?
- Yes
- No
Are you Nursing?
- Yes
- No
Do you currently experience, or have in the past, any problems in the following areas?
Please check all that apply:
- Allergy
- Blood
- Cardiovascular
- Constitutional
- Ear, Nose, Throat, Mouth
- Endocrine
- Gastrointestinal
- Genitourinary
- Hematologic/Lymphatic
- Immunologic
- Integumentary (skin)
- Musculoskeletal
- Neurologic
- Psychiatric
- Respiratory
Indicate any family history, including yourself, for the following conditions.

Please check all that apply:
Blindness
- Yourself
- Mother
- Father
- Sister
- Brother
- Grandparent
- Child
Cataract
- Yourself
- Mother
- Father
- Sister
- Brother
- Grandparent
- Child
Glaucoma
- Yourself
- Mother
- Father
- Sister
- Brother
- Grandparent
- Child
Macular Degeneration
- Yourself
- Mother
- Father
- Sister
- Brother
- Grandparent
- Child
Retinal Detachment/Disease
- Yourself
- Mother
- Father
- Sister
- Brother
- Grandparent
- Child
AIDS/HIV
- Yourself
- Mother
- Father
- Sister
- Brother
- Grandparent
- Child
Arthritis
- Yourself
- Mother
- Father
- Sister
- Brother
- Grandparent
- Child
Cancer
- Yourself
- Mother
- Father
- Sister
- Brother
- Grandparent
- Child
Diabetes
- Yourself
- Mother
- Father
- Sister
- Brother
- Grandparent
- Child
Heart Disease
- Yourself
- Mother
- Father
- Sister
- Brother
- Grandparent
- Child
High Blood Pressure
- Yourself
- Mother
- Father
- Sister
- Brother
- Grandparent
- Child
Kidney Disease
- Yourself
- Mother
- Father
- Sister
- Brother
- Grandparent
- Child
Thyroid Disease
- Yourself
- Mother
- Father
- Sister
- Brother
- Grandparent
- Child
Do you use tobacco products?
- Yes
- No
Do you drink alcohol?
- Yes
- No
Do you use other substances?
- Yes
- No
Do you participate in Sports?
- Yes
- No
If Yes, please list which sports you participate in:
Medication & Allergy List
Pharmacy Name
Pharmacy Address
Pharmacy City
LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING, INCLUDING EYE MEDICATIONS: Please include prescriptions (ex. Lipitor, Fosamax), over-the-counter medicines (ex. Aspirin, Antacids) and herbals (ex. Gingko, Ginseng). Also include the medications taken as needed (ex. Nitroglycerin).
Please include Name of Medication (Lipitor, Artificial Tears), Dosage (ex. 10 mg, 250 mg, etc), and Directions (ex. Two times per Day)
LIST ALLERGIES AND DESCRIBE REACTION:

Grand Island Optical Patient History Form

Medication & Allergy List