Grand Island Optical Patient History Form

Date:

SS#:

Date of Birth:

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:

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:

Type of Surgery:

How many hours per day do you use a computer?

Are you experiencing any of the following?

Please check all that apply:

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:

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: