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 (*).
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Last Name: *
First Name: *
Home Phone: *
Work Phone: *
Email Address: *
Date of Birth:
Social Security Number:
Single Married Divorced Widowed
Primary Care Physician:
Whom may we thank for referring you?
Name of Subscriber:
Relationship to Patient:
Self Spouse Child Other
Subscriber's Address:(if different than above)
Subscriber's Social Security #:
Vision Insurance Company:
Major Medical Insurance Company:
List any medications you currently take (prescription and over-the-counter):
Do you have allergies to any medications?
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.)
Loss of vision
Flashes/Floaters in vision
Distored vision (halos)
Loss of side vision
Sandy or gritty feeling
Foreign body sensation
Eye pain or soreness
Crossed eyes, lazy eye
Fever, weight loss/gain, other general problems
Ear, nose, throat problems (sinus, ear infection, chronic cough, dry mouth, etc.)
Vascular problems (diabetes, high blood pressure, heart pain, vascular disease)
Respiratory problems (asthma, emphysema, etc.)
Gastrointestinal problems (stomach ulcers, etc.)
Genital, kidney, or bladder problems
Muscle, bone, or joint problems (arthritis, etc.)
Skin problems (acne, warts, skin cancer, etc.)
Neurological problems (multiple sclerosis, headaches, migraines, seizures, etc.)
Psychiatric problems (anxiety, depression, insomnia, etc.)
Endocrine problems (thyroid disorder, etc.)
Blood/lymphatic problems (high cholesterol, anemia, etc.)
Allergic/immunologic problems (hay fever, lupus, Sjogrens, etc.)
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.
Heart disease or high blood pressure
Do you have visual difficulty when driving?
Do you have problems with night vision?
Do you use illegal drugs?
If so, type/amount:
Do you drink alcohol?
If so, how much?
Do you smoke?
occasional1/2 pack/day1 pack/day1+ pack/day
Have you ever had a blood transfusion?
Are you considering LASIK surgery in the next 2 years?
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
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