Medical History Form For Adults

Medical History Form For Adults

If you are booking an appointment for a child, use this form.

Please complete the information below and submit the form online or, if you prefer, print out the form after full or partial completion and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.

1Patient Information

2Insurance Information

3Medical History

4Ocular History

Today's Date*
MM slash DD slash YYYY
Name*
First Middle Initial Last
Preferred Name
Date of Birth*
MM slash DD slash YYYY
Address*
Address Line 2
City*
State*
Zip*
Country*
Social Security Number*
(Full social or last 4 digits)
Gender*
- Female
- Male
Contact Information
Phone, Cell*
Phone, Alternate
Email Address*
Background Information
Preferred Language*
Race*
Ethnicity*
Marital Status*
Employment Status*
Employer
Occupation
Communication Preference*
How were you referred to our office?*
Please Specify:
For example, if friend or family, who?

Responsible Party*
- Self
- Spouse
- Parent
- Guardian
- Other
Policy Holders Name*
First MIddle Initial Last
Policy Holders Address*
Address Line 2
City*
State*
Zip*
Country*
Cell Phone*
Email*
Policy Holders DOB*
MM slash DD slash YYYY
Policy Holders Social Security Number
(last 4 digits)
Employer
Medical Insurance*
- Yes
- No
Insurance Information
Insurance Company Name*
Relationship to Policy Holder*
Subscriber #*
Employer
Vision Plan*
- Yes
- No
Insurance Company Name*
Relationship to Policy Holder*
Subscriber ID #*