Step 1 of 6 16% Name* First Last D.O.B.*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Home Phone Day Phone Cell Phone Texting OK? Yes No Email* Enter Email Confirm Email Address* Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code HiddenSocial Security Marital Status*MarriedSingleDivorcedWidowedEmployment Status*Full-TimePart-TimeUnemployedPreferred LanguageEnglishSpanishRaceAmerican Indian or Aslaska NativeAsianAfrican AmericanHispanicNative Hawaiian/Pacific IslanderWhiteCommunication PreferrenceEmailPostalTelephoneTextHow did you find out about us?InsuranceInternetSign/LocationWebsiteYellow PagesPatient ReferralOtherReferrer's Name Insurance InformationVision InsuranceInsurance Company Member ID/SSN Group Number Relationship to the Insured Insured's D.O.B.Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Insured's Employer Name of insured person if not the patient Health InsuranceInsurance Company Member ID/SSN Group Number Relationship to the Insured Insured's D.O.B.Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Insured's Employer Name of insured person if not the patient Medical HistoryPrimary Care Doctor's Name Do you wear glasses?* Yes No Do you wear contact lenses?* Yes No How old are your current glasses/contact lenses?Do you have allergies to medications?* Yes No Please explain List any medications you take (including oral contraceptives, aspirin, over-the-counter meds and home remedies)List any ocular medications you take.List all major injuries, surgeries, and/or hospitalizations you have hadCheck any of the following you have had Crossed Eyes Lazy Eye Drooping Eyelid Macular Disease Retinal Disease Glaucoma Cataracts Eye Infections Eye Injury Other Please explain Social HistoryThis information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer. Yes, I would prefer to discuss my Social History directly with my doctor. Do you use tobacco products? Yes No If yes, what type/amount/how long? Do you drink alcohol? Yes No If yes, what type/amount/how long? Do you use illegal drugs? Yes No If yes, what type/amount/how long? Have you ever been exposed to or infected with Gonorrhea Hepatitis HIV Syphilis None of the above Family HistoryPlease note any family history (parents, grandparents, siblings, children; living or deceased) of the following.Blindness* Yes No Relationship Cataracts* Yes No Relationship Crossed Eyes* Yes No Relationship Glaucoma* Yes No Relationship Macular Degeneration* Yes No Relationship Retinal Detachment/Disease* Yes No Relationship Arthritis* Yes No Relationship Cancer* Yes No Relationship Diabetes* Yes No Relationship Heart Disease* Yes No Relationship High Blood Pressure* Yes No Relationship Kidney Disease* Yes No Relationship Lupus* Yes No Relationship Thyroid Disease* Yes No Relationship Other* Yes No Please Explain Relationship Review of SystemPlease check or fill in the blank if you have any of the following.Cardiovascular Cardiovascular Disease Congestive Heart Failure Hypertension Other Heart Condition Ear, Nose, Mouth, and Throat Dry Mouth Headaches Nose Bleeds Musculoskeletal Osteoarthritis Rheumatoid Arthritis Myasthenia Gravis Constitutional Anemia Fever Weight Gain Weight Loss Immunological AIDS/HIV Herpes Simplex Herpes Zoster Neurological Bell's Palsy Brain Tumor Epilepsy Multiple Sclerosis Endocrine Elevated Cholesterol Diabetes Thyroid Disorder Psychiatric Alcoholism Autism Brain Trauma Down Syndrome Learning Disability Gastrointestinal Gastrointestinal Disorder Inflammatory Bowel Disorder Ulcer Hematologic/Lymphatic Blood Disorder Cancer Integumentary Acne Rosacea Atopic Dermatitis Contact Dermatitis Dry Skin Lupus Psoriasis Raynaud's Disease Height Weight Please list any conditions not listed above.Please sign below to give authorization for and agree to the following: Release of your exam findings to your insurance company for reimbursement. Release of medical information to other doctors/health care professionals when a referral is indicated. Co-Pays and fees must be paid by cash or credit card at the time of your visit. Not all medical services are covered under your insurance policy. You are responsible for services that your insurance company (including Medicare) classifies as “non-covered” services.Are you a parent or guardian of the patient?* Yes No Parent/Guardian Name Signature* Hours Monday 8:00am - 6:00pm Tuesday 9:00am - 6:00pm Wednesday 9:00am - 6:00pm Thursday 9:00am - 6:00pm Friday 8:00am - 2:00pm Saturday Closed Sunday Closed
