Patient History Form For a printable form click here ATTENTION: All information given is confidential and HIPAA protected. Please note that in order for the doctor to provide a comprehensive eye exam all of this medical information is necessary and will save you time on your appointment. Step 1 of 5 20% DemographicsLocation*Please SelectFayettevilleLiverpoolToday's Date:* MM DD YYYY Full Name:*Gender:*MFBirth Date:* MM DD YYYY Title:*Mr.Mrs.MissMs.Dr.Marital Status:*SingleMarriedWidowedDivorcedSeparatedAddress:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email:* Last 4 digits of Social Security #:*Home Phone:*Cell Phone:Texting*YNCommunication Preference:*EmailPostalPhoneResponsible Party if different:Billing Address if different: Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone:Relationship to patient:Medical Insurance:Vision Insurance:Place of Employment:Work Phone:If Married, Name of Spouse:Spouse’s place of work:Name of Medical Doctor:*Phone:Pharmacy:Pharmacy Phone:Pharmacy Address: Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Previous Eye Doctor:Whom may we thank for referring you: *** PAYMENT IS EXPECTED WHEN SERVICES ARE RENDERED*** We accept Visa, MasterCard, Discover, American Express, Care Credit, and Debit Cards Ocular / Medical HistoryDo you wear glasses?*NoYesHow old are your eyeglasses?*Are you getting glasses today?*NoYesDo you wear contact lenses?*NoYesIf yes, what type?*RGPSoftDo you sleep in them?*NoYesHow frequently do you replace them?*Solution Brand?*Are they comfortable?*NoYesAre you interested in contact lenses today?*NoYesDo you wear Safety Glasses for home/work?*NoYesAre you currently experiencing any of the following problems with your eyes?Check the box if “Yes.” Blurred Vision Redness Halos / Glare Loss of Vision Eye Pain or Soreness Light Sensitivity Flashes Dryness Floaters Excess Tearing / Watering Double Vision Foreign Body Sensation Dizziness Burning Tired Eyes Itching Have you been diagnosed with any of the following ocular problems?Check the box if “Yes.” Cataracts Glaucoma Retinal Detachment Crossed Eyes Lazy Eye Drooping eyelid Eye Injury Macular Degeneration Other If other, please specify:*Are you taking any medications?*NoYesList any medications you are currently taking:*(include oral contraceptives, aspirin, over the counter, and home remedies) Are you allergic to any medications?*NoYesIf yes, please explain:* Preferred Language:*EnglishSpanishRace:*Native American/AlaskanAsianAfrican AmericanHispanicNative Hawaiian/Other Pacific IslandWhiteEthnicity:*Hispanic/LatinoNative Hawaiian/Pacific IslanderNon Hispanic/Latino Review of SystemsPlease check the box beside any problem you currently have in the following areas:Allergic / Immunologic* All Normal Allergy / Hayfever Cardiovascular / Cardiac* All Normal Arteriosclerosis Heart Disease High Blood Pressure High Cholesterol Constitutional* All Normal Fever Weight Loss Weight Gain Ears, Nose, Mouth, Throat* All Normal Sinus Congestion Dry Throat / Mouth Endocrine* All Normal Diabetes Thyroid Disease Chronic Fatigue If diabetes:* Blood Sugar A1C Years Gastrointestinal* All Normal Diarrhea Constipation Ulcers Reflux Genitourinary* All Normal Kidney Disease Ovarian / Uterine Cancer Prostate Cancer Polycystic Ovarian Syndrome (PCOS) Hematologic / Lymphatic* All Normal Anemia Bleeding Problems Breast Cancer Integumentary (Skin)* All Normal Skin Cancer Rashes Easy Bruising Musculoskeletal* All Normal Rheumatoid Arthritis Muscle Pain Joint Pain Fibromyalgia Osteoporosis Neurological* All Normal Headaches/Migraines Dizziness/Vertigo Seizures Stroke Psychiatric* All Normal Anxiety Depression Memory Loss Hallucinations ADD/ADHD Autism Alzheimer’s Dementia Respiratory* All Normal Asthma Bronchitis Emphysema Chronic Cough COPD If you checked any of the above boxes or have a condition not listed, please explain further:Are you pregnant and / or nursing?*YesNoHave you had any major surgeries and / or hospitalizations?*NoYesList all major surgeries and / or hospitalizations you have had:* Family HistoryPlease note any family history (parents, grandparents, siblings, children):Blindness Relation to You How? Cataract Relation to You Crossed Eyes Relation to You Glaucoma Relation to You Macular Degeneration Relation to You Retinal Detachment Relation to You Rheumatoid Arthritis Relation to You Cancer Relation to You Diabetes Relation to You Heart Disease Relation to You High Blood Pressure Relation to You Kidney Disease Relation to You Lupus Relation to You Thyroid Disease Relation to You Social HistoryThis information is kept strictly confidential. However, you may discuss this portion directly with your doctor if you prefer. Please check the box if you wish to discuss your Social History directly with your doctor Do you drive?*YesNoIf yes, describe any visual difficulty while driving:Do you smoke?*YesNoFormer SmokerIf you’re a current smoker, for how long? How many years?*If you’re a former smoker, for how many years were you a smoker?*When did you quit?*Do you use tobacco products?*YesNoIf yes:* Type Amount (packs) How long (years) Do you drink alcohol?*YesNoIf yes:* Type Amount per day How long Only Social Do you use illegal drugs?*YesNoIf yes:* Type Amount How long Indicate by checking the box if you have been infected with or exposed to: Gonorrhea Hepatitis HIV Syphilis MRSA Signature:*Date:* Date Format: MM slash DD slash YYYY
