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PATIENT HISTORY QUESTIONNAIRE (must be updated at each visit)
Click Here For A Printable Version of This Form
Last Name
First Name
MI
Age
Male
Female
Address
City
State
Zip
Telephone (H)
(W)
SS#  
DOB
Occupation
Employer
Single
Married
Emergency Contact/Phone#
Name of Previous Dr
Date of last eye exam
Dilated?
Referred By
How did you hear about our office?
Is anyone in your family an Eye Group patient? Y / N Who?
How many hours per day do you use a computer?
Hobbies
No
Yes
Asthma...............................
Kidney Disease........
Tuberculosis.......................
Diabetes...........................
#of years..........................
Insulin..........................
#of years..........................
Migraines..........................
Depression..........................
Any nervous disorder....
Heart Disease.....................
Ulcer.........................
Arthritis...........................
Hepatitis...........................
No
Yes
Head or spinal injuries....
Seizures, fainting.............
Lupus.......................
Temporal Arteritis................
HIV.....................
Cancer......................
Sickle cell anemia........
High blood pressure........
Stroke........
Are you pregnant........
Do you use tobacco........
Do you use alcohol..........
or other substance........
Other health problems........
History Review
Please list all medications you are currently taking (including eye drops):
List any medication you are allergic to:
What happens?:
Surgical History :
Date of last tetanus shot :
Family Physician :
PERSONAL INFORMATION
No
Yes
Cataracts...........................
Retina/macular disease.......
Crossed eyes......................
No
Yes
Cornea diseaset...............
Glaucoma........................
Other eye disorders...........
Do you wear:
Eyeglasses?:
Yes
No
Contacts?
Yes
No
Are you interested in Contact Lenses?
Yes
No
LASIK
Yes
No
Eye Surgery:
Right:
Left;
Eye Injuries:
Eye problems:
We recommend yearly eye examinations. Contact lens prescriptions expire after one year; eyeglass prescriptions after two years.
Family History: Has anyone in your family (blood relative) had any of the following in the past?
No
Yes
Glaucoma..........................
Cataracts........
Cornea disease..................
Macular/retina disease....
Retinitis pigmentosa....
Other eye problems...
No
Yes
Retinal detachment............
Diabetes...........................
Diabetic retinopathy...........
Heart problems...........
Stroke............
Other health problems.........
     CONSENT TO TREAT
By signing this form, I consent to treatment for myself and/or on the behalf of the Minor for which this information pertains. I give my permission for the doctor(s) to examine, diagnose, and initiate treatment as deemed appropriate. I further attest that I am the Parent/Legal Guardian of the Minor and have the authority to authorize care or treatment.
Signature
Date.
Vision Insurance Carrier
Insured Name
SS#
DoB
Male
Female
While the Eye Group, P.C. is happy to file my insurance for me, I understand I am responsible for all charges should my claim be denied.
SIGNATURE
Tech Signature
Physician Signature
Date.
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