Adult History Form Name(Required) First Last Address(Required) Street Address City State / Province / Region ZIP / Postal Code Work Phone:Home/Cell Phone:(Required)Email(Required) Date of Birth:(Required) MM slash DD slash YYYY Occupation: Employer: Date of Last Eye Exam: MM slash DD slash YYYY Financially Responsible Individual Primary Vision Insurance:(Required) Name of Subscriber(Required) Insurance ID Number(Required) Primary Medical Insurance:(Required) Name of Subscriber(Required) Insurance ID Number(Required) Do You Have Secondary Vision Insurance? Yes No Secondary Vision Insurance: Name of Subscriber Insurance ID Number Do You Have Secondary Medical Insurance? Yes No Secondary Medical Insurance: Name of Subscriber Insurance ID Number How did you hear about our office?(Required) I’m a returning Patient Doctor Referral (Write name in box below) Friend (Write name in box below) Yellow Pages Saw Sign / Building Insurance listing Web page Other: (Required) Name of person who referred you: MEDICAL HISTORY HAVE YOU HAD ANY OF THE FOLLOWING HEALTH PROBLEMS?Gastrointestinal(Required) Yes No Not Sure Ears/Nose/Throat(Required) Yes No Not Sure Cardiovascular(Required) Yes No Not Sure Respiratory(Required) Yes No Not Sure High Blood Pressure(Required) Yes No Not Sure Neurological(Required) Yes No Not Sure Urinary(Required) Yes No Not Sure Muscles/Bones(Required) Yes No Not Sure Skin(Required) Yes No Not Sure Eyes(Required) Yes No Not Sure Endocrine(Required) Yes No Not Sure Blood/Lymph(Required) Yes No Not Sure Allergic/Immunological(Required) Yes No Not Sure Headaches(Required) Yes No Not Sure Mental(Required) Yes No Not Sure List your medications followed by what they are for (ex. Insulin/Diabetes). Medication / Purpose(Required) Add RemoveAre you diabetic?(Required) Yes No Year of diagnosis:Are you allergic to any medication?(Required) Yes No Medications I am allergic too: Name of Primary Care Physician:(Required) First Last Date of last visit: MM slash DD slash YYYY List any surgeries: Add RemoveFAMILY HISTORY - DOES ANY OF YOUR IMMEDIATE FAMILY HAVE ANY OF THESE CONDITIONS?High Blood Pressure(Required) Yes No Who? Diabetes(Required) Yes No Who? Glaucoma(Required) Yes No Who? Macular Degeneration(Required) Yes No Who? Retinal Detachment(Required) Yes No Who? Cataracts(Required) Yes No Who? PERSONAL EYE INFORMATIONHave you had any eye surgeries, injuries or serious conditions?(Required) Yes No Please Describe: Have you had any of these symptoms in the last week (check all that apply)? Redness Dryness Sandy or gritty sensation Itching Excess watering or tearing Excess mucous discharge Blurred vision that clears upon blinking Sensitivity to smoke Sensitivity to wind Sensitivity to computer glare Sensitivity to air conditioning or heaters Sensitivity to light Sensitivity to contact lenses (dryness, irritation,etc.) If you checked anything above, are your symptoms worse: In the morning Later in the day/evening Same all day long Do you ever wear (check all that apply)? Prescription Glasses Computer Glasses Prescription Sunglasses Non Prescription Sunglasses Soft Contact Lenses Hard (Gas-permeable) contact lenses Non Prescription Reading Glasses Name or Type Tell us why you are here today (check all that apply):(Required) New Glasses New Glasses (if there is a change in prescription) New Contacts New Contacts (possibly but need more information first) Eye Health problem Eye Comfort problem Academic problem Other Do you use a computer? Yes No Number of hours per day?Are there any times when you wish your vision was better? Yes No Please describe below:IS THERE ANYTHING WE FORGOT TO ASK?Please tell us anything you would like us to know about your visit so that we can better serve you: Search: Search Request An Appointment Patient Forms Email Us
