Seal Beach Eyes

Patient Information

Name*

First Last

Phone*

Social Security Number*

Marital Status*

Single
Married
Divorced
Widowed
Other

Sex*

Female
Male

Address*

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

Email*

Employment*

Full Time
Part Time

Occupation

Company

Education

Full Time Student
Part Time Student

Medical History

Name of Family Doctor

Date of Last Visit

Medication Allergies

Non Medication Allergies*

Current Medications (Including Eye Drops)*

AIDS/HIV*

Yes
No

Ears/Nose/Throat*

Yes
No

Heart Disease*

Yes
No

Asthma*

Yes
No

Thyroid Condition*

Yes
No

Kidney Disease*

Yes
No

Stroke*

Yes
No

Cancer*

Yes
No

Headaches*

Yes
No

Cigarettes/Tobacco*

Yes
No

Alcohol*

Yes
No

Pregnant*

Yes
No

High Blood Pressure*

Yes
No

Cataracts*

Yes
No

Operations/Surgery*

Yes
No

Personal Eye Information

Name of Previous Doctor

Date of Last Exam

Glasses*

Contact Lenses*

Soft Lenses/Disposables
RGP
Conventional
None

Type/Brand*

BC

DIA

Blurred Vision*

Yes
No

Dry Eyes*

Yes
No

Floaters or Spots*

Yes
No

Double Vision*

Yes
No

Itchy Eyes*

Yes
No

Watering Eyes*

Yes
No

Eye Injury*

Yes
No

Eye Operation*

Yes
No

Explain Injury/Operation*

Insurance

Medical Insurance Plan*

Medicare
BlueCross
BlueShield
Aetna

Vision Insurance Plan*

VSP
MES
EyeMed

HIPAA ACKNOWLEDGEMENT*

Health Insurance Portability and Accessibility Act – ACKNOWLEDGE OF NOTICE OF PRIVACY PRACTICE It is often necessary to use and disclose health information that identifies you in order to treat you, to obtain payment for our services, and, to conduct healthcare operations involving our office. The Notice of Privacy Practices describes these uses and disclosures in detail. Our office is in full compliant with HIPAA, and a copy of the Notice of Privacy Practice is available if you’d like a copy for your records.

Please read and check the box if you have understood and accept this notice of privacy

Seal Beach Eyes Optometry

Patient Information

Medical History

Personal Eye Information

Insurance