Adult History Form

Please fill out the form below and submit it prior to your appointment and we will have your paperwork ready for you when you arrive. Required fields are marked with asterisks (*).

Patient Information

Last Name: *

First Name: *

Middle Initial:

Preferred Name:

Street Address:

City:

State:

Zip:

Home Phone: *

Cell Phone: *

Email Address: *

Date of Birth:

Social Security Number:

Occupation:

Employer:

Employer's Address:

Marital Status:

Single

Married

Divorced

Widowed

Primary Care Physician:

Physician Address:

Whom may we thank for referring you?

Insurance Information

Name of Subscriber:

Relationship to Patient:

Self

Spouse

Child

Other

Subscriber's Address:
(if different than above)

Subscriber's Employer:

Subscriber's Social Security #:

Subscriber's Birthdate:

Vision Insurance Company:

Policy Number:

Group Number:

Major Medical Insurance Company:

Policy Number:

Group Number:

Medical Information

List any medications you currently take (prescription and over-the-counter):

Do you have allergies to any medications?

Yes

If yes, list the medications:

List all major illnesses (glaucoma, diabetes, high blood pressure, heart attack, etc.) or injuries (concussion, etc.):

List any surgeries you have had (cataract, tonsillectomy, appendectomy):

Do you currently have any problems in the following areas? If "Yes," please provide information.

Eye disease (glaucoma, cataract, retinal disease, etc.)

Yes

Loss of vision

Yes

Blurred vision

Yes

Flashes/Floaters in vision

Yes

Distored vision (halos)

Yes

Loss of side vision

Yes

Double vision

Yes

Dryness

Yes

Mucous discharge

Yes

Redness

Yes

Sandy or gritty feeling

Yes

Itching

Yes

Burning

Yes

Foreign body sensation

Yes

Excess tearing/watering

Yes

Glare/light sensitivity

Yes

Eye pain or soreness

Yes

Tired eyes

Yes

Crossed eyes, lazy eye

Yes

Fever, weight loss/gain, other general problems

Yes

Ear, nose, throat problems (sinus, ear infection, chronic cough, dry mouth, etc.)

Yes

Vascular problems (diabetes, high blood pressure, heart pain, vascular disease)

Yes

Respiratory problems (asthma, emphysema, etc.)

Yes

Gastrointestinal problems (stomach ulcers, etc.)

Yes

Genital, kidney, or bladder problems

Yes

Muscle, bone, or joint problems (arthritis, etc.)

Yes

Skin problems (acne, warts, skin cancer, etc.)

Yes

Neurological problems (multiple sclerosis, headaches, migraines, seizures, etc.)

Yes

Psychiatric problems (anxiety, depression, insomnia, etc.)

Yes

Endocrine problems (thyroid disorder, etc.)

Yes

Blood/lymphatic problems (high cholesterol, anemia, etc.)

Yes

Allergic/immunologic problems (hay fever, lupus, Sjogrens, etc.)

Yes

Is there a family history of problems in the following areas? If so, please mark the relationship(s) to patient.

M=mother, F=father, S=sibling, GP=grandparent.

Blindness

Yes

Glaucoma

Yes

Crossed eyes

Yes

Macular degeneration

Yes

Retinal detachment/disease

Yes

Rheumatoid Arthritis

Yes

Cancer

Yes

Diabetes

Yes

Heart disease or high blood pressure

Yes

Kidney disease

Yes

Lupus

Yes

Stroke

Yes

Thyroid disease

Yes

Other

Yes

Social History

Do you have visual difficulty when driving?

Yes

Do you have problems with night vision?

Yes

Do you use illegal drugs?

Yes

If so, type/amount:

Do you drink alcohol?

Yes

If so, how much?

occasional
1/day
2-3/day
4+/day

Do you smoke?

Yes

If so, how much?

occasional
1/2 pack/day
1 pack/day
1+ pack/day

Have you ever had a blood transfusion?

Yes

Are you considering LASIK surgery in the next 2 years?

Yes

Thank you for filling out your History Form. If you would like to fill out paperwork for another family member, you can return to this form after submitting.

I have filled out this form as accurately as possible and am complete. *

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