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Douglas Minor, O.D.
Elite Optical – Professional Eye Care
1635 N Greenfield Rd Ste. 136
Mesa, AZ 85205-4011
Phone: 480.219.2412
www.eliteopticalaz.com
PATIENT INFORMATION AND MEDICAL HISTORY FORM
Please fill out as much information as you can. When you are finished, please submit this form to our office
staff.
PATIENT INFORMATION
*Required (first and last name and either a home OR cell phone)
Title____ *First____________*Last______________ MI___ Suffix____ Nickname___________
Address________________________________
________________________________
City ________________________________ ST____ Zip_______________
*Home Phone ____________________
*Cell Phone______________________
Work Phone_____________________
Other Phone_____________________
Email__________________________
Preferred Contact By _____________
DOB (mm/dd/yyyy) ______________
Sex (please circle) M or F
Marital Status:___________
Employment Status (please circle): EMPLOYED FT STUDENT PT STUDENT
Occupation/Grade____________
Employer/School_____________
Parent/Guardian______________
Race_______________________
Ethnicity____________________
Preferred Language___________
Who may we thank for referring you to our office: _____________________________
If not referred, how did you hear about Elite Optical: ___________________________
BILLING INFORMATION
*IS THE BILLING ADDRESS THE SAME? (Please circle): YES NO
Title___ First _____________ Last _______________ MI _____ Suffix ____
Address _____________________________________
_____________________________________
City ______________________________________ ST ____ Zip __________
Home Phone _______________________
Work Phone ________________________
MEDICAL HISTORY
PRIMARY CARE PHYSICIAN
Primary Care Physician and Clinic Name:_________________________________
Physician’s Address: _________________________________________________
HEALTH HISTORY
Briefly describe the main reason for having an examination today:
___________________________________________________________________
List all medications you are currently taking (including any vitamins):
___________________________________________________________________
List any eye surgeries:
____________________________________________________________________
Allergies/Alerts:
____________________________________________________________________
Describe any eye injuries:
____________________________________________________________________
Do you have any other symptoms related to this? ____________________________
Please list all eye drops you use (OTC and RX) and use: _______________________
General Health History:
_____________________________________________________________________
Other Eye Issues or Problems:
_____________________________________________________________________
Are you pregnant or nursing? (Please circle): YES NO If yes, what is the due/birth date? __________
Do you have, or ever had, any CHRONIC problems in the following areas?
YES NO
YES NO
YES NO
Migraines ___ ___
Arthritis ___ ___
Multiple Sclerosis ___ ___ Allergies/Hay Fever ___ ___
Diabetes ___ ___
Asthma ___ ___
Thyroid Problems ___ ___
Emphysema ___ ___
High Blood Pressure ___ ___
Stroke ___ ___
Anemia ___ ___
Cancer ___ ___
Are there any other conditions? Please describe here:
_________________________________________________________________________________________
FAMILY HISTORY
Family history is unknown/adopted.
Any history of the following in any family members (parents, grandparents, siblings, children)?
YES NO Relationship to patient
Poor Vision ___ ___ ______
Blindness ___ ___ ______
Eye turn (Strabismus) ___ ___ ______
Lazy Eye (Amblyopia) ___ ___ ______
Glaucoma ___ ___ ______
Macular Degeneration ___ ___ ______
Retinal Detachment/Disease ___ ___ ______
Color Blindness ___ ___ ______
Arthritis ___ ___ ______
YES NO Relationship to patient
Cancer ___ ___ __________________
Diabetes ___ ___ __________________
High Blood Pressure ___ ___ __________________
Stroke ___ ___ __________________
Thyroid Disease ___ ___ __________________
Heart Disease ___ ____ _________________
Kidney Disease ___ ___ __________________
Other Inherited Disease ___ ___ ___________________
If yes, what disease? ___ ___ ___________________
YES NO
YES NO
YES NO
Blindness___ ___
Headaches___ ___
Eyes Itch ___ ___
EYE HISTORY
Eye Turn(Strabismus)___ ___
Blurred Vision___ ___
Eyes Burn___ ___
Lazy Eye(Amblyopia)___ ___
Double Vision___ ___
Eyes Tear___ ___
Keratoconus___ ___ Eyes “Hurt” or “Tired”___ ___
Eyes Feel Dry___ ___
Glaucoma___ ___
Halos around lights___ ___
Eyes feel sandy/gritty___ ___
Cataracts___ ___
Bothered by light/sun___ ___
Flashing Lights___ ___
Macular Degeneration___ ___
Frequent Styes___ ___
Floaters___ ___
Retinal Detachment___ ___
Eyes frequently red___ ___
Mucous Discharge___ ___
Color Blindness___ ___
Infection of Eye or Lid___ ___
Drooping Eyelid___ ___
Body Sensation___ ___
Loss of Side Vision___ ___
Fluctuation Vision___ ___
Are there any other eye diseases or conditions?
__________________________________________________________________________________________
__________________________________________________________________________________________
SPECTACLE LENS HISTORY
How many hours a day do you use a computer? _______________
Describe any visual symptoms from computer use: ________________________________________________
**Please circle an answer for each question below**
Do you wear sunglasses?
YES NO
Do you have glare problems?
YES NO
Do you drive?
YES NO
Do you have visual difficulty when driving?
YES NO
Do you have problems with night vision?
YES NO
I currently wear glasses:  Full-time Part-time
If Part-time, how often/when?____________________
 Soft Rigid Gas Permeable Have you tried to wear contact lenses?  Yes No
Reason for stopping:_______________________________________________________
If not a contact lens wearer, are you interested in trying contact lenses?  Yes No
Contact Lens Wearers: Are your lenses comfortable?  Yes No
Current Brand: __________________
What solution do you use? ___________________ What is your replacement schedule? _________________
How old is your current pair? ______________________________________________
SOCIAL HISTORY
How often do you smoke/use tobacco products? _______________________________
How often do you consume alcohol? ________________________________________
Do you have  Hepatitis HIV STDs
Interests/Hobbies:
__________________________________________________________________________________________
__________________________________________________________________________________________
Thank you! Please submit this form to a member of our office staff.