Insight Vision Care
Patient’s Name: ______________________________________ Date: ____________________
Soc. Sec #: ___________________ Birth Date: ____-____-______ Sex: ________Age: _______
Address: ______________________________________________________________________
City _______________________________ State __________________ Zip ______________
Phone (H):_____________________________(Cell):__________________________Text: Y N
Email Address: _________________________________________________________________
Employer: ___________________ Occupation: _____________ Phone (W): _______________
How did you hear about our practice? _______________________________________________
Primary Care Physician: _______________________________ Phone: ___________________
Address: ______________________________________________________________________
Who is the subscriber to the insurance? _______________________ Birth Date ______________
Relationship to patient: ___________ Address: ________________________________________
Medical Insurance _______________________ Vision Insurance _______________________
Please list any medication you are taking, including eye drops, vitamins, and aspirin.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Do you have any allergies to any medications? If yes, what type? _________________________
______________________________________________________________________________
Past Surgeries: _________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Are you interested in contacts? ___________ Are you interested in Lasik? _____________
Social History: Do you smoke? ____________ How much? ___________
Have you ever smoked? ____________
Do you drink? ____________
05/11/2013
How much? ___________
Insight Vision Care
Family History: Are there any medical or eye diseases in your FAMILY? If yes, please note
relationship to patient.
Glaucoma
□ Yes
□ No
Relationship: _______________
Macular Degeneration
□ Yes
□ No
Relationship: _______________
High Blood Pressure
□ Yes
□ No
Relationship: _______________
Diabetes
□ Yes
□ No
Relationship: _______________
Turned or Lazy Eye
□ Yes
□ No
Relationship: _______________
Other
□ Yes
□ No
Relationship: _______________
REVIEW OF SYSTEMS: Do YOU currently
have any of the following problems?
YES
NO
If yes, please explain…………...…….
1. Constitutional
(general health: fever, weight loss, other)
2. Eyes (injury, glaucoma, cataract, lazy eye,
problems, other – please specify)
3. Ear/Nose/mouth/throat
(hearing loss, sinus problems, sore throat)
4. Cardiovascular (heart problems,
chest pain, irregular heart beat)
5. Respiratory (asthma, shortness of breath,
wheezing, coughing)
6. Gastrointestinal (heartburn, abdominal,
pain, diarrhea, vomiting)
7. Genitourinary (urinary problems)
8. Integumentary (skin rashes,
excessive dryness)
9. Musculoskeletal (muscle aches,
joint pain, swollen joints)
10. Neurological (numbness, weakness,
headaches, paralysis)
11. Hematologic / Lymphatic (blood
disorders, leukemia, anemia)
12. Allergic / Immunologic (hay fever,
allergies)
13. Endocrine (Thyroid problems,
pituitary problems)
14. Psychiatric
(depression, anxiety)
15. Cancer
What kind?
16. Born Prematurely
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been
accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the eye doctor to
release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the
period of such eye care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly
to the eye doctor insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill
for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
Patient Signature: (Or parent if a minor)______________________________________
05/11/2013