Patient History Form Patient History Step 1 of 5 20% Patient InformationFirst Name Middle Initial Last Name Nickname Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Marital StatusNot MarriedMarriedOtherSex Male Female Address Street Address Address Line 2 City State / ProvinceAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code SSN Last 4 - Optional Home PhoneCell PhoneEmail Occupation/Grade Employer/School What is the best way to contact you? How did you hear about us? Patient is over 18 years old* Yes No Parent/Legal Guardian/Primary Insurance Holder InformationFirst Name Middle Initial Last Name Relationship to Patient Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Last 4 of SSN Address Street Address Address Line 2 City State / ProvinceAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneEmergency Contact Emergency Contact Phone Patient History QuestionnaireHow would you rate your overall health?PoorFairGoodExcellentDo you have problems with any of these system? Please check all that apply.Gastrointestinal Yes No Please ExplainEars/Nose/Throat Yes No Please ExplainCardiovascular Yes No Please ExplainRespiratory Yes No Please ExplainNervous Yes No Please ExplainGenitourinary Yes No Please ExplainMusculoskeletal Yes No Please ExplainEndocrine (glands) Yes No Please ExplainBlood/Lymph Yes No Please ExplainSkin Yes No Please ExplainMental Yes No Please ExplainAllergic/Immune Yes No Please ExplainPlease Answer All That ApplyDiabetes? Yes No Type Date of Diagnosis Medication Allergy? Yes No Medication Names and Reactions:Other Allergies? Yes No Allergic to What? Reactions? Other Health ProblemsCurrent MedicationsDo we have your permission to access your medication history with our e-prescribing system? Yes No Have you had any operations? Yes No Type Date Do you use tobacco? Yes No Name of Family Doctor Date of Last Visit Personal Eye InformationHave you had any eye operations? Yes No Type Date Have you had an eye injury? Yes No Type Date Do you have glaucoma? Yes No Cataracts? Yes No Blurred Vision? (without glasses/contacts) Yes No Do you wear glasses? Yes No Contact Lenses? Yes No Type Dry Eyes? Yes No Difficulties driving at night? Yes No Addition Comments Family History (Relationships)Has anyone in your family been diagnosed with any of the following?High Blood Pressure Yes No Relation Macular Degeneration Yes No Relation Retinal Detachment Yes No Relation Diabetes Yes No Relation Glaucoma Yes No Relation Cataracts Yes No Relation Other Eye Condition? Yes No What Kind? Relation CommentsThis field is for validation purposes and should be left unchanged. Office Hours Monday 9:00am - 5:00pm Tuesday 9:00am - 5:00pm Wednesday 10:00am - 6:30pm Thursday 9:00am - 5:00pm Friday 8:00am - 3:00pm Saturday Closed Sunday Closed