CAPITOL HILL VISION
SEATTLE
Patient Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
DayTime Phone
-
Area Code
Phone Number
Cellphone
-
Area Code
Phone Number
Email
example@example.com
Personal Information
Gender
Female
Male
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number (Last 4 Digits Only)
Preferred Language
Race
Ethnicity
Marital Status
Employment Status
Employer
Occupation
How were you referred to our office?
Communication Preference
Eye History
Please check off any current conditions you suffer from
Glasses History
Do you wear glasses?
Yes
No
Contact Lens History
Do you wear contact lenses?
Yes
No
Medical History
When, approximately, was your last eye exam?
Where did you get your last eye exam?
When, approximately, was your last physical exam?
Who is your primary care physician?
Do you drink alcohol?
Yes
No
Sometimes
Do you smoke?
Yes
No
Sometimes
Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)
Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)
Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)
Please list all hospital surgeries you have ever had:
Please list all prescription and over-the-counter medications you take and for what conditions
Please list all drug allergies you have
Please check off any current conditions you suffer from
Primary Insurance
Please bring all insurance cards with you to your appointment.
Insurance Company Name
Insurance Company Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insured's Name
First Name
Last Name
Identification Number
Group Number
Insured's Date of Birth
-
Month
-
Day
Year
Date
Patient's Relation to Insured
Comments
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