English Medical History Form - The Vision Center of West Phoenix

Medical Insurance Name

Medical Insurance ID#

Primary Insurance Holder First Name

Primary Insurance Holder Last Name

Primary Insurance Holder DOB

Primary Insurance Holder SS#

Do you have secondary insurance?

Yes
No

used for conditional logic

Secondary Insurance Name

Secondary Insurance ID#

Secondary Insurance Holder First Name

Secondary Insurance Holder Last Name

Secondary Insurance Holder DOB

Secondary Insurance Holder SS#

end conditional logic section

Patient Name*

First Last

Patient D.O.B.*

Patient Address*

Street Address Address Line 2 City State ZIP Code

Patient Email Address*

Patient Email Address Confirmation*

Patient Cell Phone*

Patient Alternate Phone*

Primary Care Doctor Name

Primary Care Doctor Phone

Specialist Care Doctor Name

Specialist Care Doctor Phone

Do you drive more than 5 hours a day?

Yes
No

Do you work on a computer more than 5 hours a day?

Yes
No

Do your contact lenses feel dry after 8 hours of wear?

Yes
No

Are you pregnant and/or nursing?

Yes
No

Are you receiving radiation treatment?

Yes
No

Are you receiving chemotherapy?

Yes
No

Are you taking Chloroquine, Hydroxychloroquine, Plaquenil?

Yes
No

Are you taking Amiodarone?

Yes
No

Are you taking Gilenya (fingolimod)?

Yes
No

List of allergies and allergic reactions to medications, foods, latex, tape, I.V. and/or dyes?

List of current medications you're taking, and the conditions they are treating?

List of body injuries, surgeries, and/or hospitalizations?

List of eye injuries, surgeries, and/or problems?

Have you ever been exposed or infected with Gonorrhea, Syphilis, Herpes, Hepatitis, HIV (Aids)?

Yes
No

Tobacco Use?

Don't Smoke
Former Smoker
Current Some Day Smoker
Current Every Day Smoker

Alcohol?

Don't Drink
Social Use Only
1-2 Drinks Daily
Alcohol Dependence

Recreational Drugs?

Are any of these conditions in your family?

Glaucoma

Relation

Macular Degeneration

Relation

Diabetes

Relation

Heart Disease

Relation

High Blood Pressure

Relation

Retinal Detachment

Relation

Thyroid Disease

Relation

Blindness

Relation

Cataract

Relation

Crossed Eyes

Relation

Arthritis

Relation

Cancer

Relation

Kidney Disease

Relation

Lupus

Relation

Do you currently, or have you ever had any problems in the following areas?

Fever, Weight loss/gain

Yes
No

Skin Problems

Yes
No

Headaches

Yes
No

Migraines

Yes
No

Seizures

Yes
No

Loss of Vision

Yes
No

Blurred Vision

Yes
No

Distorted Vision/Halos

Yes
No

Loss of Side Vision

Yes
No

Double Vision

Yes
No

Eye Dryness

Yes
No

Eye Mucous Discharge

Yes
No

Eye Redness

Yes
No

Eye Sandy or Gritty Feeling

Yes
No

Eye Itching

Yes
No

Eye Burning

Yes
No

Eye Foreign Body Sensation

Yes
No

Eye Excess Tearing/Watering

Yes
No

Glare/Light Sensitivity

Yes
No

Eye Pain or Soreness

Yes
No

Chronic Infection of Eye or Lid

Yes
No

Styes or Chalazion

Yes
No

Flashes/Floaters in Vision

Yes
No

Tired Eyes

Yes
No

Thyroid/Other Glands

Yes
No

Allergic/Immunologic

Yes
No

Psychiatric

Yes
No

Allergies/Hay Fever

Yes
No

Sinus Congestion

Yes
No

Runny Nose

Yes
No

Post-Nasal Drip

Yes
No

Chronic Cough

Yes
No

Dry Throat/Mouth

Yes
No

Asthma

Yes
No

Tuberculosis

Yes
No

Chronic Bronchitis

Yes
No

Emphysema

Yes
No

Diabetes

Yes
No

Heart Pain

Yes
No

Heart Murmurs

Yes
No

High Blood Pressure

Yes
No

Vascular Disease

Yes
No

Hepatitis/Other Liver Disease

Yes
No

Diarrhea

Yes
No

Constipation

Yes
No

Ulcers

Yes
No

Genitals/Kidney/Bladder Disease

Yes
No

Rheumatoid Arthritis

Yes
No

Muscle Pain

Yes
No

Joint Pain

Yes
No

Anemia

Yes
No

Bleeding Problems

Yes
No

Any other medical history not listed?

Great job! One more step. Use your phone camera to photograph the front and back of your medical insurance card. If you are on a desktop you can easily attach the image.

Front

Back