Patient History Form Name* First Last Date of Birth 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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin 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 todaySignatureOccupation Employer Family Doctor Are you pregnant/nursing Yes No What 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* Yes No Previous if yes indicate frequency/past use Alcohol* Yes No Previous if yes indicate frequency/past use Other Drugs* Yes No Previous if yes indicate frequency/past use Family History (If yes, please indicate who in the family) Macular Degenerationwho in the family Glaucomawho in the family Cataractswho in the family Cancerwho in the family High Blood Pressurewho in the family Diabeteswho in the family Thyroidwho in the family Conditionwho in the family Cholesterolwho in the family NONEPlease list any other condition you would like us to know aboutHow you were referred to us Insurance Company Yellow pages Another patient Internet search/website Social Media Newspaper/advertisement Insurance InformationInsurance Provider* Insurance ID Number* Group Number* Guarantor 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) Dilation I Authorize my child's eyes to be dilated I decline to have my child eyes dilated Contact 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 time NO, I do not need a CL The 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 representativeHiddenDate MM slash DD slash YYYY Section Break
* We are closed between 1:00 PM -2:00 PM for lunch.