Patient History Form
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2North Valley Eye Care, P.C. • Dr. Justin L. Kohls • • • • Dr. Michelle A. Kohls
Patient History Form
Name:____________________________________________ Nickname:___________________ Age:_____ Date of Birth:____/____/_____
If child, Name of Parent(s):_______________________________ Email Address:______________________________________________
Address:_________________________________________________________ City:________________________ Zip:________________
Home Phone:_______________________ Daytime Phone:________________________ Cell Phone: ______________________________
Communication preference?
Telephone
Postal
Text
Email:________________________________________________
Employer/Occupation:_______________________________________ Hobbies/Interests:______________________________________
Preferred language?
English
Spanish
Ethnicity?
Hispanic or Latino
Native Hawaiian/ Pacific Islander
Not Hispanic or Latino
Race?
White
Hispanic
Black or African American
Asian
American Indian
Native Hawaiian
How did you hear about our office?
Saw our sign
Insurance Website
Postcard
Yellow Pages
Referral by friend or family If so,
Name of person who referred you here? ______________________ and relationship to you?________________
Other_______________
Name of Vision Insurance or
None _________________________________________________________________________________
Name of primary person on Vision Plan or
Self_____________________________ Primary Insured’s Employer:______________________
Name of Medical Insurance or
None ____________________________________ Primary Care Doctor’s Name:_____________________
Name of primary person on Medical Plan or
Self___________________________ Primary Insured’s Date of Birth:______/______/______
If using Medicare, please provide your Social Security Number: ___________________________
Visual and Medical History
Date of last eye exam:_________________ By Whom?:_______________________
Date of Last Physical Exam:________________ Height: _______ Weight:_______ Last Blood Pressure Reading: _______/_______
What type of exam are you here for?
Spectacle exam
Contact lens exam
Both
Medical Eye Visit
Do you presently wear?
Eyeglasses
Sunglasses
What Type?
Single Vision
Progressive
Lined Bifocal
Do you currently wear contact lenses?
Yes
No If yes, which brand?_____________________
Don’t know
Have you ever worn contact lenses?
Yes
No
If No, are you interested in trying contact lenses?
Yes
No
Please check any symptoms you are currently experiencing:
None
Blurred vision at Distance
Eye Discomfort/Irritation
Itching
Double Vision
Blurred Vision at Near
Redness
Eye Pain
Other concerns:
_____________________________
Blurred Vision on Computer
Dryness
Tired Eyes
Do you suffer from seasonal allergies?
No
Yes
Do they affect your eyes?
No
Yes
Do you use a computer?
No
Yes Approximate # of hours per day? ________
Personal Eye History
Cataracts
Glaucoma
Retinal Detachment
Loss of Vision
Macular Degeneration
Lazy Eye
Head or Eye Injury
Dry Eye Syndrome
Other _____________________________________________________________________________________________________
Eye Medications
(Please list all drops including over-the-counter ) _____________________________________________________________________
Eye Surgery
Cataract
Refractive
Eye Muscle Surgery
Other_________________________________________________________________
Medications ___________________________________________________________________________________________
Allergies to medications_________________________________________________________________________________
Social History
:
Do you drink alcohol?
No If yes, how often?
Occasionally
1 per day
2-3/day
4+/day
Do you smoke?
No
If yes how often?
Occasionally
1/2 pack/day
1 pack/day
1+ pack/day
Do you use illegal drugs?
No
Yes
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