New Patient Registration Form

Medical History Form

Please fill out the form below with your personal information & medical history. Thank you!
Today's Date

MonthDayYear
Date
Name

First NameLast Name
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
E-mail
PERSONAL INFORMATION
Gender
Date of Birth

MonthDayYear
Date
Social Security #
Occupation
Race/Ethnicity
Preferred Language
INSURANCE INFORMATION

Please fill out the details for each section that applies to you. If you do not have Medical or Vision Insurance, leave blank and skip ahead to the next section.
MEDICAL INSURANCE DETAILS:
Medical Insurance Provider
Medical Insurance Policy Number
Medical Insurance Group Number
Medical Insurance Responsible Party or Subscriber Name
Insurance Subscriber Date of Birth

MonthDayYear
Date
VISION INSURANCE DETAILS:

If you do not have Vision Insurance, please skip this section.
Vision Insurance Provider
Vision Service Plan (VSP) requires the subscriber's Social Security number to verify eligibility.
Vision Insurance Policy Number (Subscriber's SSN)
Vision Insurance Group Number
Vision Insurance Responsible Party or Subscriber Name
Insurance Subscriber Date of Birth

MonthDayYear
EMERGENCY CONTACT
Emergency Contact:

First NameLast Name
Relationship
Contact Number

Area CodePhone Number
MEDICAL HISTORY
Date of Last Eye Exam

MonthDayYear
Date
Name of Your Medical Doctor
Doctor's Phone Number
Date of Last Medical Exam

MonthDayYear
Date
Do you have any allergies to medications?
If Yes, please explain...
List any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies)
List all major surgeries, injuries, and/or hospitalizations you've had...
Check any of the following that you have had...
Are you pregnant or nursing?
Do you wear glasses?
If yes, how old is your present pair of lenses?
Do you wear contact lenses?
If yes, how old is your present pair of contact lenses?
Type of contact lenses you wear:
Are they comfortable?
FAMILY HISTORY
Note any family history (parents, grandparents, siblings, children; living or diseased) for the following conditions...

Other
If you have checked anything above, please not the relationship to you.
SOCIAL HISTORY
This information is kept strictly confidential. You may discuss this portion directly with the doctor if you prefer.
Do you able to drive?
Do you have visual difficulty when driving?
Do you use tobacco products?
If yes, type/amount/frequency?
Do you drink alcohol?
If yes, type/amount/frequency?
Do you use illegal drugs?
If yes, type/amount/frequency?
Have you ever been exposed or infected with:
REVIEW OF SYSTEMS

Do you currently, or have you ever had any problems in the following areas?
EYES
CONSTITUTIONAL
INTEGUMENTARY
NEUROLOGICAL
ENDOCRINE
EARS/NOSE/MOUTH/THROAT
RESPIRATORY
VASCULAR/CARDIOVASCULAR
GASTROINTESTINAL
GENITOURINARY
BONES/JOINTS/MUSCLES
LYMPHATIC/HEMATOLOGIC
ALLERGIES
PSYCHOLOGICAL
If you have checked ANY of the boxes above or have a condition not listed, please explain and list all medications:
Should be Empty:

Medical History Form