Patient Health History Form "*" indicates required fields Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.Office Location*Select LocationBoulderEast Las VegasHorizon RidgePahrumpSummerlinWarm SpringsWater StreetW SaharaName* First Last Preferred Name Date of Birth* MM slash DD slash YYYY Patient ID Doctor Date* MM slash DD slash YYYY Appointment Time Category Last Encounter Date/Time Reason for Visit*Medical Insurance Vision Insurance Your doctor recommends annual digital photos of the back of the eye. These photos assist your doctor in the identification of potentially blinding eye disorders and diseases such as: glaucoma, macular degeneration, diabetic eye diseases, etc.The photos are not covered by vision insurance, is that okay to do today? Yes No I would like more information Patient Signature*Demographic InformationLast Name First Name Preferred Name Date of Birth MM slash DD slash YYYY Email Home PhoneWork PhoneCell PhoneSSN Occupation Place of Employment Primary Insured InformationLast Name First Name Date of Birth MM slash DD slash YYYY SSN 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 Phone Number* Pupil DilationIt will be necessary to dilate your pupils in order to perform a complete and thorough eye examination. This allows the doctor to obtain a better view of the back of your eyes. The dilating drops typically last 3-4 hours. During this time you may find it difficult to focus at near and you may be sensitive to light. You will be provided with post-dilation sunglasses. We strongly recommend caution when driving or operating equipment or machinery after dilation. If you feel you would not be able to drive or return to work, we can reschedule the dilated portion of your exam. In the event that it becomes necessary for us to release your records to or request your records from another healthcare professional, your written permission is required. Please read and sign below.Understanding the risk and benefits of dilation:* I accept I refuse Patient Signature (Patient or Guardian)*Insurance/Financial Responsibility - Please Read CarefullyOur office attempts to obtain accurate insurance benefits for each patient. We must be provided with up-to-date information to do so. We do expect each patient to be familiar with his or her insurance benefits before coming in. Filing insurance is not a guarantee of payment. Any amount not paid by insurance will be your responsibility. In these situations, after the patient pays the co-payment, co-insurance, any deductible amount or any charge not covered by insurance, we will automatically file an insurance claim for reimbursement of the remainder of the balance directly to us. If your insurance program is not one we have contracted with, it is your responsibility to pay for the services and be reimbursed by your insurance. We will provide you with appropriate documentation to do so. Please be aware - in either situation, the ultimate responsibility for financial obligations lies with you. We appreciate your cooperation in this matter. If at any time, you have questions regarding insurance or billing, do not hesitate to contact our office. We will make all reasonable attempts to assist you. Thank you.It is policy of this office to require: Payment in full or at least one-half before the order can be placed The balance of the fee must be paid at the time the order is dispensed A $25.00 charge will be assessed for returned checks All orders are final when placed WE THANK YOU FOR TAKING THE TIME TO COMPLETE THIS FORM AND FOR CHOOSING US TO PROVIDE YOUR VISION/EYE HEALTH CARE.Date* MM slash DD slash YYYY Patient Signature (Patient or Guardian)*Health InformationWith your best vision correction on, have you suffered from any of the following: Near Vision Blur Dry Eyes Seeing Flashes Double Vision Distance Vision Blur Watery Eyes Seeing Haloes Indoor Glare Middle Distance Blur Pain in/around Eyes Outdoor Glare Red Eyes Seeing spits/lines Headaches Do you have any special vision requirements (occupation/computer/hobbies/sports) How many hours per day do you spend on a computer. Date of your last physical exam Month Day Year Family Doctor Smoking Status* Current every day Current some days Former Heavy Tobacco Light Tobacco Never Do you currently drink alcohol* Yes No Could you currently be pregnant?* Yes No Do you currently wear eyeglasses?* Yes No What kind? Single Vision Bifocal Progressive Do you currently wear contact lenses? Yes No Brand How many hours? Please list all the medications you are currently taking: Please list any medication allergies: Family HistoryPlease check all that apply.Cancer Yourself Mother Father Sister Brother Son Daughter Neurological Problems Yourself Mother Father Sister Brother Son Daughter Depression/Anxiety/ADD Yourself Mother Father Sister Brother Son Daughter Heart Disease Yourself Mother Father Sister Brother Son Daughter High Blood Pressure Yourself Mother Father Sister Brother Son Daughter Lung Disease Yourself Mother Father Sister Brother Son Daughter GI Disease Yourself Mother Father Sister Brother Son Daughter Kidney/Bladder/Genital Yourself Mother Father Sister Brother Son Daughter Infectious Disease Yourself Mother Father Sister Brother Son Daughter Autoimmune Disease Yourself Mother Father Sister Brother Son Daughter Arthritis Yourself Mother Father Sister Brother Son Daughter Skin Disease Yourself Mother Father Sister Brother Son Daughter Diabetes Yourself Mother Father Sister Brother Son Daughter Blood Disease Yourself Mother Father Sister Brother Son Daughter Thyroid Disease Yourself Mother Father Sister Brother Son Daughter High Cholesterol Yourself Mother Father Sister Brother Son Daughter Cataracts Yourself Mother Father Sister Brother Son Daughter Glaucoma Yourself Mother Father Sister Brother Son Daughter Macular Degeneration Yourself Mother Father Sister Brother Son Daughter Blindness Yourself Mother Father Sister Brother Son Daughter Lazy Eye/Eye Turn Yourself Mother Father Sister Brother Son Daughter Retinal Disorders Yourself Mother Father Sister Brother Son Daughter Eye Injuries/Surgeries Yourself Mother Father Sister Brother Son Daughter CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
