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San Bruno Eye Care Center
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2022-01-28T20:37:08+00:00
San Bruno Eye Care Center
Patient Form
Basic Information
To 'Submit' form, all required fields in this section must be filled out.
Name
(Required)
First
Middle
Last
Sex
(Required)
Male
Female
Date of Birth
(Required)
MM slash DD slash YYYY
Age
Marital Status
(Required)
Single
Married
Separated
Divorced
Widowed
SSN Last 4
(Required)
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Employment Status
Worker
Employee
Self employed
Contractor
Unemployed
Occupation
Allow Messaging
Home
Text
Email
To 'Submit' form, please enter at least one method of contact.
Home Phone
Cell Phone
Email Address
Employer Info
Employer Name
Phone
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Other Contact Info
Person responsible for charges
Relationship to Patient
Phone
Emergency contact
Emergency contact relationship
Phone
Visit Information
Last eye exam date
MM slash DD slash YYYY
First Visit
Yes
No
Reason for current visit
Referred by
Eye Health
Check all that apply
Amblyopia
Burning Eyes
Drooping Eyelid
Eye Turn
Foreign Body Sensation
Headaches
Loss of Vision - Central
Redness
Check all that apply
Blurred Vision - Far
Cataracts
Dry Eyes
Floaters/Spots
Glaucoma
Itchy Feeling
Loss of Vision - Side
Retinal Detachment
Check all that apply
Blurred Vision - Near
Double/Distorted Vision
Eye Surgeries
Fluctuating Vision
Glare/Light Sensitivity
Infection of eye/lid
Mucus/Discharge
Tearing/Watery Eyes
General Health
Check all that apply
Allergies/Hay Fever
Cancer
Chronic Cough
Gastrointestinal Problems
Kidney Disease
Thyroid/Endocrine Disease
Check all that apply
Asthma/Respiratory
Cardiovascular/High BP
Diabetes
Heart Attack/Stroke
Psychiatric Depression
Skin Disorders
Check all that apply
Blood Disorders
Chronic Bronchitis
Emphysema
Headaches/Migraines
Rheumatoid Arthritis
Weight Loss/Gain
Do you smoke tobacco products?
Yes, I smoke everyday
Yes, I smoke occasionally
No, I'm a former smoker
No, I've never been a smoker
Family History
High blood pressure
Yes
No
Relation
Diabetes
Yes
No
Relation
Glaucoma
Yes
No
Relation
Macular degeneration
Yes
No
Relation
Retinal detachment
Yes
No
Relation
Cataracts
Yes
No
Relation
Physician / General Practitioner
Physician Name
Phone
Last Medical Exam Date
MM slash DD slash YYYY
Medications
(Required)
None
Yes
List of Medications
(Required)
Add
Remove
Enter all medications and the conditions they treat
Allergies
(Required)
No known allergies
Yes
Allergies
(Required)
Add
Remove
Enter all medications or substances to which the patient is allergic
Please answer the following questions
Are you pregnant or nursing?
Yes
No
Do you have trouble driving at night?
Yes
No
Do you wear glasses?
Yes
No
Do you wear contacts?
Yes
No
Do you experience blur, headaches, or eyestrain with computer use?
Yes
No
Are you interested in laser (refractive) surgery to correct your vision?
Yes
No
Vision Insurance Information
Insurance Company
ID Number
Group Number
Patient's relationship to insured
Self
Spouse
Child
Other
Primary Insured's Sex
Male
Female
Name of the Insured
Insured's Phone Number
Insured's Date of Birth
MM slash DD slash YYYY
Last 4 of SSN
Other Insurance Information
Insurance Company
ID Number
Group Number
Patient's relationship to insured
Self
Spouse
Child
Other
2nd Insured's Sex
Male
Female
Name of the Insured
Insured's Phone Number
Insured's Date of Birth
MM slash DD slash YYYY
Additional Comments Is there anything else we should know? Let us know below.
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