Annual Health & Vision Health History

Annual Health & Vision Health History

A Chance To Grow Vision Clinic
Demographics
Name:*

First NameMiddle InitialLast Name
Date of Birth:*

MonthDayYear
Date
MaleFemaleOther
Gender if different than assigned:
Pronouns:
Nickname / Preferred Name:
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address:*
example@example.com
Home PhoneCell (Call)Cell (Text)Email
Primary language spoken at home:*
Race / Ethnicity:
YesNo
YesNo
Emergency Contact Name:

First NameLast Name
Relation:
Emergency Contact Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Email Address:
example@example.com
YesNo
Name of Parent/Guardian (1):

First NameLast Name
Phone Number (1):
If different from aboveFormat: (000) 000-0000.
Name of Parent/Guardian (2):

First NameLast Name
Phone Number (2):
If different from aboveFormat: (000) 000-0000.
Review of Symptoms

Do you have a health condition in any of the following areas? (Specify)*

Rows	Please Explain
Constitution / Neuro / Psych
ENT / Respiratory / Pulmonary
Cardiovascular
High Blood Pressure / Diabetes
Immune / Allergy
Vision / Ocular

Do you or an immediate family member (Mom/Dad, Sibling, or Child) have currently, or in the past, any of the following health conditions?

Eye Condition:

Rows	Personal	Family (list relation)
Cataract
Glaucoma
Macular Degeneration
Retinal Detachment
Strabismus / Amblyopia (Eye Turn or Lazy Eye)
Other (specify)