Medical History Record For faster service, please complete the following form prior to arriving at our office.Appointment Date MM slash DD slash YYYY Is this for a child? Yes Patient’s Name First Middle Last Gender Male Female Social Security Number Parent’s Name First Middle Last Employer Occupation Spouse’s Employer Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneEmail How did you find out about our office? Internet Search Doctor's Referral Friend Who referred you? Do you have insurance? Medical Vision Please bring all insurance cards with you to your appointment. Medical InsuranceInsurance Company Name Insurance Company Phone Number Insured's Name First Last Identification Number Group Number Insured's Date of Birth MM slash DD slash YYYY Patient's Relation to Insured Vision InsuranceInsurance Company Name Insurance Company Phone Number Insured's Name First Last Identification Number Group Number Insured's Date of Birth MM slash DD slash YYYY Patient's Relation to Insured Personal Medical InformationDo you have problems with any of these systems?If Yes, please check box. Gastrointestinal Nervous System Mental Ear/Nose/Throat Genitourinary Endocrine (Glands) Cardiovascular Musculoskeletal Blood/Lymph Respiratory Skin Allergic/Immunologic Headaches Surgeries (what type & when) Are you in good health? Yes Any allergic reactions to medications or other substances? Yes please list Name of general physician Do you smoke? Yes how much? Do you drink alcohol? Yes how much? Do you take medications? Yes Please list names & how often Do you use other substances? Yes Do you have family history of any of the following? If Yes, please check box. Diabetes Glaucoma High blood pressure Macular Degen Retinal Detachmt Cataracts Please explain any boxes you have checked Do you have any of the following? If Yes, please check box. Dry Eyes Eye Surgeries Wear Glasses Blurred Vision Eye Injuries Wear Contacts Any eye problems at this time? Please explain Are you interested in laser vision correction? Yes Please sign below that: 1. I have reviewed all information above and it is correct to the best of my knowledge. 2. I authorize the release of any medical information necessary to provide the most beneficial and complete visual examination. I understand that I am financially responsible for all charges whether or not paid by insurance. Payment is due at the time services are rendered.SignatureDate MM slash DD slash YYYY
