NEW PATIENT HEALTH HISTORY FORM

NEW PATIENT HEALTH HISTORY FORM

NEW PATIENT HEALTH HISTORY FORM

In order to provide you the best possible care, please complete this form and bring it to your first appointment. Along with your insurance cards and license. All information is strictly CONFIDENTIAL
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Contact Information

​​​​​​​Guardian Information

(if patient is under 18 years of age or person responsible of charges to the account)

​​​​Patient Information

​​​​​​​Primary Insurance Information

​​​​​​​Secondary Insurance Information

​​​​​​​Additional Insurance Information (Vision)

Primary Care Provider

​​​​​​​PATIENT HISTORY

Eye Conditions

Eye Concerns

Vision Concerns​​​​​​​

Medical History

General:

Psychological:​​​​​​​

Gastrointestinal:​​​​​​​

Skin/Integumentary:​​​​​​​

Ear, Nose & Throat:​​​​​​​

Cardiovascular:​​​​​​​

Muscular/Skeletal:​​​​​​​

Endocrine:​​​​​​​

Hematology/Lymp:​​​​​​​

Neurology:​​​​​​​

Respiratory:​​​​​​​

Gyn/Urinary:​​​​​​​

Allergy/Immunology:

PFSH – Past Ocular History​​​​​​​

Medication List (please bring current medication list if additional paper is needed)

Social History

​​​​Family Medical History

(check all that apply to blood relatives, parents, grandparents, siblings only)

Hypertension

Hyperthyroid​​​​​​​

Type 1 Diabetes:​​​​​​​

Type 2 Diabetes:​​​​​​​

​​​​​​​Family Eye History

Cataract

Macular Degeneration​​​​​​​

Glaucoma​​​​​​​

Blindness​​​​​​​

Color Blindness​​​​​​​

Keratoconus​​​​​​​

Other