Patient History Form Name* First Last Date of Birth Date Format: MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country HOME PHONEWORK PHONECELL PHONE*E-MAIL ADDRESS* * I attest that I have not had any symptoms or any exposure to anyone who has COVID- 19. I also accept the risk and consent to a visit todaySignatureOccupationEmployerFamily DoctorAre you pregnant/nursingYesNoWhat brought you in todayAre you interested in New spectacles Anti-Reflective lens Clip-ons Contact Lenses Lasik Safety glasses Light weight glasses Sunglasses Anti-fatigue/Blue light lens Personal Eye History: Check all that apply Eye surgery Eye injury Wearing an eye patch Retinal detachment Lazy eye/eye turn Color blindness None Review of Systemscheck all that apply or check None General Health* cancer fatigue developmental disabilities weight loss/gain None Ear/Nose/Throat* cough hearing loss earache sinus congestion dry mouth sore throat None Cardiovascular* pacemaker high blood pressure heart disease congestive heart failure None Respiratory* asthma bronchitis emphysema COPD sleep apnea None Gastrointestinal* GERD Crohn's gallbladder colitis ulcer acid reflux celiac None Gastro-urinary* Bladder issues kidney disease prostate disease STD None Muscle/Skeleton* back pain arthritis fibromyalgia gout muscular dystrophy None Integumentary* itching eczema psoriasis rosacea cold sores shingles None Neurological* seizures migraines stroke epilepsy cerebral palsy multiple sclerosis None Psychological memory loss depression ADHD anxiety bipolar None Endocrine* Diabetes Type I or II sweating hormonal dysfunction thyroid Hashimoto None Lymphatic/Blood* anemia bleeding problems high cholesterol leukemia None Allergies/Immune* environmental food Lupus Sjorgrens HIV autoimmune None Do you currently take any medications? Please list and indicate dosage and frequency if known NoneDo you have any allergies to medications? Please list with reactions NoneDo you use OR have you ever used the following productsTobacco*YesNoPreviousif yes indicate frequency/past useAlcohol*YesNoPreviousif yes indicate frequency/past useOther Drugs*YesNoPreviousif yes indicate frequency/past useFamily History (If yes, please indicate who in the family) Macular Degeneration Glaucoma Cataracts Cancer High Blood Pressure Diabetes Thyroid Condition Cholesterol NONEPlease list any other condition you would like us to know aboutHow you were referred to usInsurance CompanyYellow pagesAnother patientInternet search/websiteSocial MediaNewspaper/advertisementGuarantor information required if under the age of 18Please list who will be the guarantor for this account if patient is under the age of 18NameCell PhoneAddress (if different from patient) DilationI Authorize my child's eyes to be dilatedI decline to have my child eyes dilatedContact Lens Evaluation Contact lens evaluations are $58-$128 depending on your prescription and the type of contact lens used to meet your needs.YES, I would like to update my CL prescription prescription at this timeNO, I do not need a CLThe contact lens evaluation includes trial contact lenses, any neccessary follow up visits, as well as training needed to help insert and remove your contact lenses. If you are a current contact lens wearer, a new evaluation is performed each time you are seen by a doctor.Acknowledgement of Receipt of this NoticeThis Practice is concerned about the privacy of our patient’s health care information. Our intent is to make you aware of the possible uses and disclosures of your protected health information and your privacy rights. The delivery of your healthcare services will in no way be conditioned upon your signed acknowledgement. If you decline to provide a signed acknowledgement, we will continue to provide your treatment and will use and disclose your protected health information for treatment, payment, and health care operations when necessary.* I acknowledge that I have received the Notice of Privacy Practices for Vision Plus.Signature of patient/authorized representativeDate Date Format: MM slash DD slash YYYY
* We are closed between 1:00 PM -2:00 PM for lunch.