MedicalHistoryForm

Medical History Form

Welcome to our office. Please fill out this form as thoroughly as possible. A save button is located at the bottom of the form in the event that you need to continue at a later time.
Full Name*

First NameMiddle NameLast Name
Todays date

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Gender*
Date of Birth*

MonthDayYear
Age
Last Four Digits of Social Security Number (SSN)*
*SSN will be used for gathering insurance information prior to your appointment
Email*
example@example.com
Cell Phone Number*

Area CodePhone Number
Occupation and Employer
If student: Grade level
If student: School name
How did you hear about our office?

VSP ListGoogleYelpInternetWalk InReferredOther
Reason for eye exam? (check all that apply)

Routine Eye ExamDry eyesBlurry Vision DistanceScratched/Broken GlassesBlurry Vision NearLost GlassesOther
Medical Insurance Name

KaiserBlue CrossPPOBlue ShieldAetnaOther
Does your company offer a Flexible Spending Plan (FSA)?
Do you participate in the FSA Program?
Does your company offer a Flexible Spending Account (FSA), Health Savings Account (HSA) or Health Reimbursement Account (HRA) or Medical Reinbursment Account (MRA)?

FSAHSAMRADon't Know.
Do you currently participate in the FSA, HSA or MRA Program?

YesNo
Date of Last Eye Exam*

MonthDayYear
Years of Current Glasses/Contacts
Name of Previous Optometrist or Ophthalmologist. In what city?
Date of Last Physical

MonthDayYear
Date
Physician's Name
Location of Medical Care

KaiserSetonSutterOther
Check the conditions that apply to YOU:*

DiabetesHypertension / High blood pressureCholesterolThyroidAsthmaHeart ProblemsAnxietyDepressionNone / Not SureAcid RefluxOther
Check the eye conditions/diseases that apply to YOU:*

GlaucomaMacular DegenerationCataractsEye turn / Lazy EyeDry / Watery EyesRetinal DetatchmentNone / Not SureBlindnessOther
Check the conditions that apply FAMILY members:*

DiabetesHypertension / High blood pressureCholesterolThyroidAsthmaHeart ProblemsAnxietyDepressionNone / Not SureAcid RefluxOther
Check the eye conditions/diseases that apply to any FAMILY members:*

GlaucomaMacular DegenerationCataractsEye turn / Lazy EyeDry / Watery EyesRetinal DetatchmentNone / Not SureBlindnessOther
Are you currently taking any medications or eye drops?*

YesNo
Please List Medications and Dosages
Do you have any allergies? (ex: food, medication or metals?)*
Seasonal Allergy (Pollen)Metals / NicklePenicillinsSulfa
Please list any additional allergies:
Have you ever had any infection / disease / injury / surgery of the eye? *
Please list any infections, diseases, or injuries of the eye, which eye and date of occurance:
Please list any previous or future eye surgeries and which eye:
Do you notice floaters, flashes of light or double vision?*
Since when and which eye?
Do you experience regular headaches? *

Do you currently or have you ever consumed alcohol, cigarettes/tobacco, or any other substances? *
If so which?

AlcoholCigarettes / vapeTobaccoMarijuana / CannabisOther SubstancesOther
How many packs or drinks per week? (If monthly please specify)
Do you get motion sickness, fall asleep when reading or get dizzy at 3D movies?*

YesNo
Have you or any immediate family members had cancer?*

YesNo
Do you experience eye strain or fatigue on a computer?*

YesNo
Do you have separate computer glasses?*

YesNo
Do you have or wear prescription sun glasses?*

YesNo
Do you wear contact lenses? If so what type?*
Brand of Contact Lens worn?

AcuvueCIBACooperBausch and LombOther
Please type in your current contact lens powers, base curves, and diameter.
Please write your contact lens prescription for both eyes (Right and Left)
Or upload a photo of your current contacts.

Browse Files

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Are you interested in updating or getting fitted for contact lenses during your upcoming visit? *
Do any immediate family members wear glasses or contacts?*
If so who?

MeMotherSiblingDaughterFatherSonOther
Feel free to attach any photos/videos related to external eye problems:

Browse Files

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Kindly inform us of any additional concerns, preferences, or special accommodations we should be aware of in preparation for your appointment.
Should be Empty:

Medical History Form