Patient History Form

Name: Family Optometric Group
Address: 1545 West 5th St, Suite 100, Oxnard, CA, 93030, US
Telephone: 805-382-2020
Price range: $000 - $300

The following information is required by insurance and allows us to provide you with the best care possible.

Date
MM slash DD slash YYYY
Name
First Last
Date of Birth
MM slash DD slash YYYY
Age
Address
City
Zip code
Phone (h)
Phone (w)
Phone (c)
M F Gm Gf Social Security #
M F Gm Gf Drivers License #
Occupation (or grade)
Employer (or school)
Emergency contact
and telephone numbers
Whom may we thank for referring you to our office?
Family members living at home: (please list names and ages)
EYE / VISION HISTORY
Do you experience, or have you experienced…
- Blurry vision, Loss of vision, Double vision?
- Halos / Glare / Light Sensitivity? (outside, at work, night driving or other
- Dry / Stinging / Gritty / Tired eyes?
- Watery or Mucous discharge?
- Itchy eyes?
- Red eyes or Eyelid infections
- Flashes of light or Floating spots
- Frequent headaches
How many hours a day do you use a desk computer (at home, work, and/or school)
How many hours a day do you use a laptop (at home, work, and/or school)
How many hours a day do you use a tablet / iPad (at home, work, and/or school)
Please list sports you play
Please list hobbies
Have you worn contact lenses before?
- Yes
- No
If yes, what type?
Are you interested in wearing contacts now?
- Yes
- No
Are you interested in LASIK?
- Yes
- No
Would you like thinner, lighter lenses for glasses?
- Yes
- No
Do you have a back-up pair of glasses?
- Yes
- No
Do you have sunglasses?
- w/prescription
- Transitions
- w/out Rx
- None
Please list any other concerns that you may have regarding your eyes

PERSONAL/ FAMILY MEDICAL HISTORY Do YOU or your IMMEDIATE family have

	Self	Parent	Bro/Sis	Child	No
Arthritis
Cancer
Diabetes
Heart Disease
High Blood Pressure
Thyroid Disease
Skin Disorder
Asthma
Allergies
Eye Disease/Injury
Eye Surgery
Lazy Eye
Cataracts
Glaucoma
Macular Degeneration
Blindness

Other (please list)
Please list any major hospitalizations, surgeries, or injuries you have had
Are you pregnant or nursing?
Primary Care Physician
Specialist
for
Specialist
for
I have filled-out/reviewed the separate list of medications I use on a regular basis (Please Initial)
Are you allergic to any medications? No Yes If so, please list
PERSONAL SOCIAL HISTORY
- Do you use tobacco products?
- Do you drink alcoholic beverages?
- Do you use illegal drugs?
How will you settle your account today?
- Cash
- Check
- Credit Card
I hereby assign all insurance benefits to Family Optometric Group, and understand I am financially responsible for all charges (whether or not they are covered by insurance) and any service charges (18%).
M F Gm Gf Signature

Patient History Form

EYE / VISION HISTORY

I hereby assign all insurance benefits to Family Optometric Group, and understand I am financially responsible for all charges (whether or not they are covered by insurance) and any service charges (18%).

Office Hours