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Adult History Form

 

Please fill out the form below and submit it prior to your appointment and we will have your paperwork ready for you when you arrive. 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.

 

Patient Information

Last Name: *

First Name: *

Middle Initial:

Preferred Name:

 

Street Address:

City:

State:

Zip:

 

Home Phone: *

Work Phone: *

Email Address: *

 

Date of Birth:

Social Security Number:

Occupation:

Employer:

Employer's Address:

Marital Status:

Single  Married  Divorced  Widowed  

 

Primary Care Physician:

Physician Address:

 

Whom may we thank for referring you?

 

Insurance Information

Name of Subscriber:

Relationship to Patient:

Self  Spouse  Child  Other  

Subscriber's Address:
(if different than above)

Subscriber's's Employer:

Subscriber's Social Security #:

Subscriber's Birthdate:

Vision Insurance Company:

   Policy Number:

   Group Number:

Major Medical Insurance Company:

   Policy Number:

   Group Number:

 

Medical Information

List any medications you currently take (prescription and over-the-counter):

Do you have allergies to any medications?

Yes No

If yes, list the medications:

List all major illnesses (glaucoma, diabetes, high blood pressure, heart attack, etc.) or injuries (concussion, etc.):

List any surgeries you have had (cataract, tonsillectomy, appendectomy):

 

Do you currently have any problems in the following areas? If "Yes," please provide information.

Eye disease (glaucoma, cataract, retinal disease, etc.)

 

Yes No

 

Loss of vision

 

Yes No

 

Blurred vision

 

Yes No

 

Flashes/Floaters in vision

 

Yes No

 

Distored vision (halos)

 

Yes No

 

Loss of side vision

 

Yes No

 

Double vision

 

Yes No

 

Dryness

 

Yes No

 

Mucous discharge

 

Yes No

 

Redness

 

Yes No

 

Sandy or gritty feeling

 

Yes No

 

Itching

 

Yes No

 

Burning

 

Yes No

 

Foreign body sensation

 

Yes No

 

Excess tearing/watering

 

Yes No

 

Glare/light sensitivity

 

Yes No

 

Eye pain or soreness

 

Yes No

 

Tired eyes

 

Yes No

 

Crossed eyes, lazy eye

 

Yes No

 

Fever, weight loss/gain, other general problems

 

Yes No

 

Ear, nose, throat problems (sinus, ear infection, chronic cough, dry mouth, etc.)

 

Yes No

 

Vascular problems (diabetes, high blood pressure, heart pain, vascular disease)

 

Yes No

 

Respiratory problems (asthma, emphysema, etc.)

 

Yes No

 

Gastrointestinal problems (stomach ulcers, etc.)

 

Yes No

 

Genital, kidney, or bladder problems

 

Yes No

 

Muscle, bone, or joint problems (arthritis, etc.)

 

Yes No

 

Skin problems (acne, warts, skin cancer, etc.)

 

Yes No

 

Neurological problems (multiple sclerosis, headaches, migraines, seizures, etc.)

 

Yes No

 

Psychiatric problems (anxiety, depression, insomnia, etc.)

 

Yes No

 

Endocrine problems (thyroid disorder, etc.)

 

Yes No

 

Blood/lymphatic problems (high cholesterol, anemia, etc.)

 

Yes No

 

Allergic/immunologic problems (hay fever, lupus, Sjogrens, etc.)

 

Yes No

 

 

Is there a family history of problems in the following areas? If so, please mark the relationship(s) to patient.

M=mother, F=father, S=sibling, GP=grandparent.

Blindness

 

Yes No

M

F

S

GP

 

Glaucoma

 

Yes No

M

F

S

GP

 

Crossed eyes

 

Yes No

M

F

S

GP

 

Macular degeneration

 

Yes No

M

F

S

GP

 

Retinal detachment/disease

 

Yes No

M

F

S

GP

 

Rheumatoid Arthritis

 

Yes No

M

F

S

GP

 

Cancer

 

Yes No

M

F

S

GP

 

Diabetes

 

Yes No

M

F

S

GP

 

Heart disease or high blood pressure

 

Yes No

M

F

S

GP

 

Kidney disease

 

Yes No

M

F

S

GP

 

Lupus

 

Yes No

M

F

S

GP

 

Stroke

 

Yes No

M

F

S

GP

 

Thyroid disease

 

Yes No

M

F

S

GP

 

Other

 

Yes No

M

F

S

GP

 

 

Social History

Do you have visual difficulty when driving?

Yes No

Do you have problems with night vision?

Yes No

 

Do you use illegal drugs?

Yes No

If so, type/amount:

 

Do you drink alcohol?

Yes No

If so, how much?

occasional
1/day
2-3/day
4+/day

 

Do you smoke?

Yes No

If so, how much?

occasional
1/2 pack/day
1 pack/day
1+ pack/day

 

Have you ever had a blood transfusion?

Yes No

 

Are you considering LASIK surgery in the next 2 years?

Yes No


 

Thank you for filling out your History Form. If you would like to fill out paperwork for another family member, you can return to this form after submitting.

 

I have filled out this form as accurately as possible and am complete. *

 
 

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Telephone: 503-722-7737     22400 South Salamo Road, Suite 100     West Linn, OR 97068     Notice of Privacy Practices

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