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Patient Information Form


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18629 SW Tualatin Valley Hwy
Aloha, OR 97006
Phone: 503-649-7566
Fax: 503-649-0123

Patient Information Form

Completing this form now will make your visit more punctual and thorough.
All items in red are required.

Office

Name

Date of Birth

Age

Address

Drivers License

Exp.

City

State

Zip

Home Phone

Occupation

Email

Employer

First Visit
Yes No

Work Phone

Referred By

Are you pregnant or nursing?
Yes No

Family Doctor

Vision Insurance Information

Vision Insurance Co.

Policy #

Group #

Patient SS #

Primary Insured SS #

Medicare Number

Primary Insured SS #

Are you a member of HMO?
Yes No

If yes which HMO?

Reason For Request: Check all that apply
Exam Glasses Contacts Laser Vision Consultation Other
Do you wear sunglasses with UV protection? Yes No

Medical History Form:
To help our office better serve your specific needs, please check all that apply.
Please leave blank for a NO answer.
No change since Last Eye Exam (Skip to below by clicking here)

Eye History

Headaches	GlareLight Sensitivity	Tired Eyes	Amblyopia(lazy eye)
Eye Infection	Excess Tearing/Watering	Redness	Eye Pain or Soreness
Drooping Eyelid	Sandy or Gritty Feeling	Itching	Fluctuating Vision
Crossed Eyes	Blurred Vision Distance	Dryness	Double Vision
Floaters or Spots	Distorted Vision (halos)	Burning	Blurred Vision Near
Loss of Side Vision	Foreign Body Sensation	Loss of Vision	Mucous Discharge

General Health Condition

Fever	Muscles, Bones, Joints	Weight Loss
Kidney	Ears, Nose, Throat	Neurological
Allergic	Respiratory (Asthma)	Gastrointestinal
Skin	Psychiatric	Blood/Lymph
Endocrine	Cardiovascular	AIDS/HIV
Anemia	Heart Attack/Stroke	Rheumatoid Arthritis
Joint Pain	Bleeding Problems	Diabetes
Genitals/Kidney/Bladder	Vascular Disease	Emphysema
Sinus Congestion	Runny Nose	Chronic Bronchitis
Post-Nasal Drip	Chronic Cough	Dry Throat/ Mouth
		Other System

Family History

Arthritis	Macular Degeneration	Heart Disease
Cancer	Retinal Detachment	Kidney Disease
Lupus	Crossed Eyes	Thyroid Disease
Stroke	Amblyopia (Lazy Eye)	Glaucoma
Diabetes	Cataract(s)	Blindness
High B.P	Color Blindness	Other

Currently taking medication(s) - (prescription and over the counter)

select from list	or type in here...
1. I take		for this condition:
2. I take		for this condition:
3. I take		for this condition:
4. I take		for this condition:
5. I take		for this condition:

If you take additional medications, please list them here.

Drug Allergies: Yes No
If yes, list the medications:

For an Emergency during office or after hours please call:
ABC Vision Source

After Hours 503-970-6694

If you are unable to reach the doctor on call, please go to the Emergency Room.

Upon submitting your request, we will call you or send an e-mail to verify that we have received your information.
Thank you for your request!