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Hours & Location
- Our Eye Doctors
- The Staff
Eye Care Services
Eyeglasses & Contacts
Insurance Information
Contact Us

Home » Patient Forms » Patient History Form

Patient History Form

Name(Required)

First Middle Last

SS#

Address

Street Address City ZIP / Postal Code

Home Phone

Cell Phone

Work Phone

DOB

MM slash DD slash YYYY

Occupation:

Employer

Emergency Contact:

Relation:

Phone Number

Date of Last Eye Exam:

MM slash DD slash YYYY

Dilated?

Yes

No

E-Mail Address

Vision Insurance:

2'° Vision Insurance:

Primary "Medical“:

Plan Member:

Date of Birth:

MM slash DD slash YYYY

Members Ins. ID:

Members SS#:

Relation to Patient:

2'° Medical”:

Members ID:

SS#:

Date of Birth:

MM slash DD slash YYYY

Person Responsible for patient:

Referred by:

PATIENT MEDICAL HISTORY

How ís your general health?

Do you have any problems with any of these systems† (Please answer yes or no for each one)

Gastrointestinal

Yes

No

Nervous

Yes

No

Endocrine (Glands)

Yes

No

Ears/Nose/Throat

Yes

No

Urinary

Yes

No

Blood/Lymph

Yes

No

Cardiovasculár

Yes

No

Muscles/Bones

Yes

No

Allergic/lmmunologists

Yes

No

Respiratory

Yes

No

Skin

Yes

No

Headaches

Yes

No

High Blood Pressure

Yes

No

Eyes

Yes

No

Mental

Yes

No

If "Yes" please explain:

Diabetes?

Yes

No

If yes, please specify Type 1 or Type 2

Date of diagnosis:

MM slash DD slash YYYY

Allergies to Medications?

Yes

No

Which medications?

FAMlILY HISTORY

High Btood Pressure

Yes

No

Relation:

Diabetes

Yes

No

Relation:

Glaucoma

Yes

No

Relation:

Macular degeneration

Yes

No

Relation:

Retinal detachment

Yes

No

Relation:

Cataracts

Yes

No

Relation:

PERSONAL EYE INFORMATION

Do you have a'ny eye conditions or problems?

Yes

No

What kind?

Have you had any eye operations?

Yes

No

Type:

Have you had an eye injury?

Yes

No

Kind:

Do you have glaucoma?

Yes

No

Cataracts?

Yes

No

Macular degeneration?

Yes

No

Retinal detachment?

Yes

No

Do you wear glasses?

Yes

No

Contact Lenses?

Yes

No

Dry eyes?

Yes

No

Blurred Vision?

Yes

No

Type?

Additional Information you would like to mention:

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Patient Forms

Orange County Eyecare Optometry

1201 N Rose Dr., Suite 100
Placentia, CA 92870

Phone: 714-528-2566
Email: staff@eyecareoptometry.net
(Do not send personal health information by email.)

Monday: 8:30 AM - 5:30 PM
Tuesday: 8:30 AM - 5:30 PM
Wednesday: 8:30 AM - 5:30 PM
Thursday: 8:30 AM - 5:30 PM
Friday: 8:30 AM - 5:30 PM
Saturday: 8:00 AM - 12:00 PM
Sunday: Closed

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Contact Us
What’s New
Disclaimer
Privacy Policy
Career Opportunities

Orange County Eyecare Optometry
1201 N Rose Dr., Suite 100
Placentia, CA 92870
Phone: 714-528-2566
https://www.eyecareoptometry.net

Schedule Appointment

Speak Field

Monday: 8:30 AM - 5:30 PM
Tuesday: 8:30 AM - 5:30 PM
Wednesday: 8:30 AM - 5:30 PM
Thursday: 8:30 AM - 5:30 PM
Friday: 8:30 AM - 5:30 PM
Saturday: 8:00 AM - 12:00 PM
Sunday: Closed

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Patient History Form

PATIENT MEDICAL HISTORY

FAMlILY HISTORY

PERSONAL EYE INFORMATION

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PERSONAL EYE INFORMATION

Orange County Eyecare Optometry

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