History

History
Select one *

Mr. Mrs. Ms. Miss.
Select one *

Married Single Divorced Widowed Domestic Partner
Name *

First Name Last Name
Sex *

Male Female
Prefered Name *
Home Phone Number *

Area Code Phone Number
Work Phone Number *

Area Code Phone Number
Mobile Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Employer *
Race *
Ethnicity *
Occupation *
Best way to contact me during the day *

Home Phone Work Phone Mobile Phone Email
Birth Date *

Month Day Year
Date
Age *
Social Security # *
Last Eye Exam *

Month Day Year
Date
Primary Language *
Special Needs *
Parent or Guardian *
Employer *

Medical History
Do you have any allergies to medications? *

Yes No
If Yes explain
Do you have a list of your meds with you? If yes, do not list meds below

Yes No
List any medications you take (including oral contraceptives, asprin, over the counter medications and home remedies)
List all major injuries, surgeries and/or hospitalizations you have had
Name of Medical Doctor
Last Medical Exam

Month Day Year
Date
Do you drive?

Yes No
If Yes, do you have visual difficulty when driving?

Yes No
If yes, please describe
Do you wear glasses?

Yes No
If yes, how old is your present pair of lenses?
Do you wear contact lenses?

Yes No
If yes, how old is your present pair of lenses?
Type of contact lenses?

Hard Soft Extended Wear (sleep in them)
Are they comfortable?

Yes No
Are you interested in contact lenses (if not already wearing)?

Yes No
Are you interested in eye surgery (such as LASIK)?

Yes No

Social History

This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer
I would prefer to discuss my Social History information directly with my doctor. If yes, skip to the last question

Yes No
Are you pregnant and/or nursing?

Yes No
If yes, how far along?
Do you use tobacco products?

Yes No
If yes, type / amount / how long?
Do you drink alcohol?

Yes No
If yes, type / amount / how long?
Have you ever been exposed to or infected with:

Gonorrhea Hepatitis HIV Syphilis
How were you referred to our office?

Family Friend Phone book Internet
Should be Empty: