Dr. Trevor J. Cleveland - Optometric Physician 1717 Centennial Blvd., Suite 2 
	Springfield, Oregon 97477 
	541.747.0616
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Patient History Form

Please fill out the form below and submit it prior to your appointment and we will have your paperwork ready and completed for you when you arrive. If you have not scheduled your appointment yet, you may use our online appointment request form or give us a call. Required fields are marked with asterisks (*).

 

The security of your information is very important to us. This form is fully secure and your information will be protected. To learn more about the security measures used on this form, click the security logo to the right.

 

General Information

Patient Name: *

Home Phone: *

Work Phone: *

Cell Phone

Email Address: *

Can you receive texts?

  Yes    No  

Preferred method of contact: *

Home  Work  Cell  Email  Text  

 

Street Address:

City:

State:

Zip Code:

 

Social Security Number:

Birthdate:

Age:

 

Employer (or School):

Occupation (or Grade):

Spouse (or parent) name:

 

Date of Last Vision Exam:

 

How did you hear about our office?

I am a previous patient

Friend or relative:  

Another doctor:  

Yellow pages, which book:  

Insurance plan directory:  

Other:  

 

Personal Medical History

Primary Care Physician *

Hayfever

Asthma

Eczema

Arthritis

Eye Injury

Glaucoma

Cancer

Cataracts

Diabetes

Eye Surgery

Heart Disease

High Blood Pressure

Kidney Problems

Thyroid Problems

  Other (please list):

 

Current Medications
(Over the counter or prescription medications)

Antihistamines:  

High Blood Pressure:  

Diuretic (Water Pill):  

Birth Control:  

Diabetes Meds.:  

Anti Depressants:  

Eye Drops:  

Others:  

Allergies to Meds.:  

 

Family Medical History
For each condition selected, enter the relation this blood relative is to you.

Blindness:  

Glaucoma:  

Diabetes:  

Cancer:  

 

Do you experience...?
(check all that apply)

Glare or Reflection

Trouble seeing at night

Uncomfortable glasses

Double Vision

Burning

Sore Eyes

Eye Strain

Redness

Itchiness

Nausea

Sensitivity to light

Blurry distance vision

Blurry near vision

Gritty feeling in eyes

Headaches

Objects floating in vision

Flashes of light

Dryness

  Other:

 

Visual Needs - Do you...?
(check all that apply)

Have problems with night driving?

Use a computer?

Have only one pair of glasses?

Wear bifocals?

Want information on thinner, lighter lenses?

Prefer not to wear glasses at times?

Spend time outdoors?

Have prescription sunglasses?

Do work that requires safety glasses?

Want information about corrective vision and laser surgery (ex. LASIK)?

 

What sport activities do you participate in (if any)?

What kind of contact lenses have you tried wearing (if any)?

 

Would you like a trial contacts?

  Yes    No  

 

List any problems with your present contact lenses or glasses:

 

Payment & Insurance

Medical insurance company:

Do you participate in a flexible (cafeteria) spending account through your employer?

  Yes    No  

How will you settle your account today?

Check
Cash
Credit Card


I hereby authorize my insurance benefits be paid directly to Complete Vision Center and I am financially responsible for non-covered services.

I AGREE (please type your full name to indicate that you agree.)


 
 

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