Gold Canyon Eye Center
Medical History Questionnaire
Today’s Date:___________________
Patient’s Name: _________________________________ Preferred Name: _______________________
DOB: __________
Sex: ___Male ___ Female Email: _______________________________
Address: _____________________________________________________________________________
_____________________________________________________________________________
Home Phone: ________________ Work Phone: ______________ Cell Phone: _____________________
Circle your preferred method of contact: Phone Text Message Email
Circle your preferred contact number: Home Work Cell
What is your occupation? _______________ Are you a student? _____ If yes, what year? ___________
Referred by: ______________________
Parent or Legal Guardian Names: ____________________ Occupation: __________________________
____________________ Occupation: _________________________
Relationship to Patient: _______________ Phone Number: ______________________________
Emergency Contact Person and Phone Number: ______________________________________________
Relationship to Patient: _______________________
How many hours daily do you spend on a screen, including computers, smart devices, eReaders and video
games? ___________
The federal government has asked that all physician offices collect information on patients’ language,
race, ethnicity, height, and weight. We are asking for your help in completing this information, however
you are not required to respond. If you decline to respond, please check here
Preferred Language: __________________ Ethnicity (circle): Non-hispanic/Latino Hispanic/Latino
Race (circle): American Indian/Alaska Native Asian African American Caucasian
Hispanic/Latino Native Hawaiian/Pacific Islander Mixed Races Other: __________
Height: ________
Weight: ________
Medical History
Primary Care Physician name and phone number: ____________________________________________
Last Eye Exam: ____________ Eye Doctor (if not here): ______________________________________
Do you have any allergies to medications (circle)? Y N If Yes, explain: _________________________
List all eye medications you use (including prescription and over the counter): _____________________
_____________________________________________________________________________________
List all other medications you use (including oral contraceptives and over the counter): ______________
_____________________________________________________________________________________
List all eye injuries and/or eye surgeries you have had: _______________________________________
_____________________________________________________________________________________
Have you been diagnosed with any of the following eye conditions? Please check all that apply.
 Blindness
 Amblyopia/Lazy Eye
 Cataract
 Thyroid Eye Disease
 Implant Lens Right Eye
 Retinal Detachment
 Implant Lens Left Eye
 Diabetic Retinal Disease
 Dry Eyes
 Strabismus/Wandering Eye
 Corneal Dystrophy
 Macular Degeneration
 Eye Cancer
 Other: ___________________________
 Glaucoma
 Hypertension Retinal Disease
Vision & Vision Correction History
Check any of the following eye symptoms you currently experience.
 Change in Distance
 Mucous Discharge or Crusted Lids
 Change in Near Vision
 Eye Pain
 Fluctuating Vision
 Dryness or Burning
 Double Vision
 Sandy or Gritty Feeling
 Loss of Side Vision
 Excess Tearing
 Flashes of Light
 Eye Strain with Reading or Computer
Work
 Light Sensitivity
 Other: _________________________
 New Spots of Floaters
 Itching
Have you ever worn contact lenses (circle)? Y N If Yes, what type/brand? ______________________
Review of Systems (Please check all that apply.)
Cardiovascular
 High Blood Pressure
 High Cholesterol
 Cardiovascular Disease
Constitutional
 Dizziness
 Excess Thirst
 Excess Urination
Endocrine
 Diabetes Type I
 Diabetes Type II
 Thyroid/Other Glands
Gastrointestinal
 Hepatitis
Hematologic/Lymphatic
 Breast Carcinoma
 Temporal Arteritis
Immunologic
 Histoplasmosis
 Sarcoidosis
 Lyme Disease
 Sjogren’s Syndrome
Integumentary
 Lupus
Musculoskeletal
 Arthritis
Neurological
 Headaches
 Multiple Sclerosis
 Myasthenia Gravis
Psychiatric
 Bi-Polar
 Depression
Respiratory
 Lung Cancer
 COPD
 Sarcoidosis
Other
 _________________________________
 _________________________________
Family History
Check if there is a history of any of the following conditions in your immediate family (parents,
grandparents, aunts, uncles, siblings).
 Diabetes
 Retinal Disease
 High Blood Pressure
 Amblyopia/Lazy Eye
 Rheumatoid Arthritis
 Crossed/Wandering Eye
 Retinal Detachment
 Glaucoma
 Macular Degeneration
 Other: _______________________
Social History (circle)
Do you drive? Y N
Do you drink alcohol? Y N
Do you or have you ever used tobacco products? Y N
If Yes, which status describes you(circle)? Former Smoker
Do you use recreational drugs? Y N
Every Day Smoker
Some Day Smoker
Blue Cross Blue Shield Insurance Patients:
We will bill Blue Cross Blue Shield for your exam. We will be happy to provide you with a duplicate
copy of your itemized invoice to submit to Blue Cross Blue Shield for your frame, lenses, lens options, or
contact lenses.
_____________________________________________________________________________________
Patient Acknowledgement Signature
Date
Acknowledgement of Payment Policy
Please present your insurance card at the time of your visit. We will bill your insurance on your behalf,
however if for any reason the services are denied or applied toward your deductible, you will be
responsible for the charges. We accept VISA, Mastercard, and Discover cards and debit cards with those
logos. Personal checks are accepted with a valid driver’s license. One-half of your bill is necessary to
start your order for glasses or contact lenses. The balance is due at pick up.
I understand and agree that regardless of my insurance status, I am responsible for the balance on
my account for any services rendered.
____________________________________________________________________________________
Patient Acknowledgement Signature
Date
Acknowledgement of Receipt of Notice of Privacy Practices
I _____________________________________, have been informed of the privacy practices for the office
of Lars J. Carlson, O.D. and Trina L. Cheng, O.D. I understand that I can request a complete detailed
copy of the document.
_____________________________________________________________________________________
Patient Signature
Date