Patient History Form (Secure)
Patient Information
* indicates a required field.
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  (xxx-xxx-xxxx)
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  (xxx-xxx-xxxx)
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  (mm/dd/yyyy)
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VERY IMPORTANT! NEW PATIENTS ONLY:
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  (name of friend or relative)
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Another Doctor
Insurance List
Saw Sign/Building
Newspaper/Radio/TV
Yellow Pages
Website
Other
At Total Family Eye Care we promise to care for and treat every patient’s eye care and health with utmost attention and respect. We will provide the highest quality of care available and stand behind our eyewear. Your eye health and quality of life will always be our focus.
Insurance Information
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  (mm/dd/yyyy)
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  (mm/dd/yyyy)
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Cash
Check
Credit Card
Lifestyle Questions
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Blurry Vision
Cataracts
Crossed eye/Eye turn
Eye Infections
Flash of light
Glaucoma
Headaches
Itchiness
Macular Degeneration
Retinal Detachment
Tearing
Uncomfortable glasses
Burning
Corneal Abrasions
Double Vision
Eye Injury
Floaters/Spots
Grittiness
Iritis/Uveitis
Lazy Eye
Occasional dryness
Sunlight Sensitivity
Trouble seeing at night
Uncomfortable glasses
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Patient Medical History
The information in this confidential case history form is critical to the evaluation of your vision and health.
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  (mm/dd/yyyy)
CURRENT MEDICATIONS (Rx or Over the Counter) (List name of medications including eye drops, vitamins, & birth control pills)
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Allergies
Arthritis
Blood/Lymph
Bronchitis
Cancer
Diabetes
Digestive
Ears/Nose/Throat
Endocrine
Eczema/Rashes
Fatigue
Genitourinary
High Blood Pressure
Integumentary (Skin)
Kidney
Muscle/Bone
Neurological
Psychological
Respiratory
Sinus
Throat Infections
Thyroid
Unusual weight losses/gains
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Patient Eye History
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  (mm/dd/yyyy)
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Family Medical/Eye History (Check all that apply)
Is there a family medical history of any of the following:
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