Medical History - Georgia Eye Center

If you do not yet have an appointment, please call our office at (713) 664-4760 or use our online
Appointment Request Form to schedule an appointment before submitting your information to us.

Last Name

First Name

Appointment Date

Sex

Male

Female

Other

Address

Date of Birth

Social Security Number

Phone Number

Email Address

Occupation

Employer

Student?

Yes

Name of Nearest Relative

Relationship to Relative

Relative's Phone #

Marital Status

Minor

Single

Married

Life Partner

Legally Separated

Divorced

Widowed

Responsible party
If the patient is the responsible party (skip this section).
If the patient is not the responsible party (complete this section).

Last Name

First Name

Address

Date Of Birth

Social Security Number

Phone Number

Occupation

Employer

Please list two people who could be notified in case of an emergency

First Name

Last Name

Relationship

Address

Phone

How were you referred to us? Please list name and relationship.

Please list all insurances below, both vision and medical.
Also, please remember to bring all insurance cards with you to your appointment so that we can make a copy of them.
The social security number of the Policyholder is not a requirement for the completion of this form, but we will be unable to verify your insurance coverage without it. This form uses the highest level of security available on the web, but if you would rather give it to us by phone, call us at (713) 664-4760 and ask for the appointment desk.

Do you have insurance?

Yes

Insurance Company Name

Insurance Company Address

Name of Insured (Policyholder)

ID / Policy / Subscriber Number

Group or Employer Name:

Group Number

Policyholder's D.O.B.

Soc Sec# of Insured (Policyholder)

Patient's Relation to Insured:

Although our main focus is on your eyes (no pun intended!), your eyes are a part of your entire body. Your lifestyle, eyhnic origin, health problems that you may have, and medications that you may be taking -- including OTC, vitamins, and holistic / herbal preparations -- can have an important inter-relationship with the condition of your eyes and your prescribed eye care.

We want to give you the best eye care available, so we thank you for answering the following questions. Your answers are for our records only and are confidential.

General Health
Please list everything that you are currently taking. Include prescription, non prescription (over-the-counter), aspirin, vitamin supplements and holistic or herbal preparations.
-- or --

Not taking anything. Tell us if you have any allergies (such as latex, pollen, drugs, food, food additives or insect stings).

-- or --

No known allergies. Describe the purpose of this appointment.

-- or --

The purpose of this appointment is a routine eye exam.

What is your ethnicity?

Asian

Black

Caucasian

Hispanic

Other

Do you drink alcohol?

Occassionally

1/day

2-3/day

4+/day

Do you smoke?

Never

Quit

1/2 pack a day

1 pack a day

1+ pack a day

Do you exercise?

Occassionally

Daily

Several times a week

Once a week

What types of exercise?

Walk

Run/jog

Swim

Golf

Active Sports

Yoga

Gymnastics/aerobics

Eye Health I

Do you currently wear glasses? (check all that apply)

Yes

Full time

Part time

Distance

Reading

What type of glasses do you own? (check all that apply)

Single Vision

Progressive

Trifocals

Bifocals

Safety Glasses

Sports Glasses

Back Up Glasses

None

Other

Do you use a Computer? (if yes how many hours per day.)

Please describe any problems that you are having with your eyeglasses.

Contact Lenses:

Do you currently wear contact lenses?

Yes

How long have you been wearing contacts?

Have you ever tried wearing contact lenses and stopped?

Yes

If you answered 'Yes' above, what was your reason for stopping?

Are you interested in using contact lenses to change or enhance your eye color?

Yes

If you wear contact lenses, do your backup eyeglasses have your correct prescription?

Yes

Answer questions (a) through (f) below only if you currently wear contact lenses.

a. What type or brand of contacts do you wear?

b. How old are your current lenses?

c. How often do you replace or dispose of your contact lenses?

d. What brand of solution do your lenses soak in overnight?

e. What is your typical wearing schedule? Hrs/day Days/wk -- or no regular schedule

f. Please describe any problems you are having with your contact lenses.

Eye Health III

Have you ever had an injury to either of your eyes?

Yes

If you checked 'Yes', please use the text box to tell us about it.

If you have ever had any type of eye surgery, please give us the information below. Type of surgery: Month and Year: Doctor: Phone: ( )

I would like to be evaluated for refractive laser surgery (LASIK).

Yes

I would like to be evaluated for a NON-surgical method to correct my vision (CRT).

Yes

What was the approximate month and year of your last eye exam?

Where did you get the exam?

Use this space for additional comments or information -- or if you have a specific issue concerning your eye health that you want to discuss with the doctor when you come in for your appointment.

Do you have a hobby or special interest

What do you like to do in your spare time?

We like to keep you informed -- and we enjoy remembering you on special occasions: May we email you approximately twice yearly to inform you of the latest news in the area of eye health?

Yes

May we send you seasonal and birthday greetings via email?

Yes

(Your email address is never shared with anyone else. It will be used only for the purposes listed above.)

Please scroll up and review your responses before submitting this information.

Thank you for choosing us for your eye care. We look forward to seeing you!