Name: Image Eyecare Optometry
Address: 451 Blossom Hill Road, Ste 10, San Jose, CA, 95123, US
Telephone: (408) 281-3926
Price range: $000 - $300

Please email or fax your medical insurance card (front and back) to us in advance of your appointment: info@imageeyecare.com Fax: (408) 281-2515

Please fill in the form below and submit.

Please also complete our COVID - 19 Questionnaire and our Optomap 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.
Patient Information
Name*
First Middle Last
Today's Date*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Number*
Please provide a telephone number, with area code, so we can contact you.
Cell Phone
Work Phone
Email Address
Please provide your email address.
Employer
Occupation
Date of Birth*
MM slash DD slash YYYY
Social Security Number (last 4 digits only!)
Please enter a number from 0000 to 9999.
Race/Ethnicity
Preferred Language
Gender
- Female
- Male
Who may we thank for referring you to our office?
Date of Last Medical Exam
Name of Medical Doctor
Doctor's Phone Number
Date of Last Eye Exam
Current Height
Current Weight
Spouse or Guardian (If Applicable)
Medical History
Do you have any allergies to medications?
- No
- Yes
If Yes, list medication(s) and reaction below:
List any medications you take including oral contraceptives, aspirin, OTC medicines, etc.:
Include Name of Medication, Dosage, Frequency Taken
List all major injuries, surgeries and/or hospitalizations you have had:
Check any of the following that you have had:
- Crossed Eyes
- Lazy Eye
- Drooping Eyelid
- Prominent Eyes
- Cataracts
- Glaucoma
- Iritis/Uveitis
- Macular Degeneration
- Retinal Disease of Detachment
- Eye Infections
- Eye Injury
- Corneal Problems
- Other Eye Disorders
If Other Eye Disorders, please explain:
Are you pregnant or nursing?
- No
- Yes
Do you wear glasses?
- No
- Yes
If Yes, how old is your present pair of lenses?
Do you wear contact lenses?
- No
- Yes
If Yes, how old is your present pair of lenses?
Type of Contact Lenses:
- Rigid
- Soft
- Extended Wear
- Other
Are they comfortable?
- No
- Yes
Family History
Note any family history (parents, grandparents, siblings, children, living or deceased) for the following conditions. When listing relationship, if a grandparent, please specify maternal or paternal.
Disease/Condition
- Blindness
- Cataract
- Crossed Eyes
- Glaucoma
- Macular Degeneration
- Retinal Detachment or Disease
- Arthritis
- Cancer
- Diabetes
- Heart Disease
- High Blood Pressure
- Kidney Disease
- Lupus
- Thyroid Disease
- Other
If Other, please explain:
If Yes to any of the above, please explain:
Social History
This information is kept strictly confidential. You may discuss this portion directly with the doctor if you prefer. Please check the box below of you prefer to discuss with the doctor instead.
I prefer to discuss my Social History information directly with my doctor.
- Yes
Do you drive?
- No
- Yes
If Yes, do you have visual difficulty when driving?
- No
- Yes
If Yes, please describe:
Do you use tobacco products?
- No
- Yes
If Yes, list type/amount/how long:
Do you drink alcohol?
- No
- Yes
If Yes, list type/amount/how long:
Do you use illegal drugs?
- No
- Yes
If Yes, list type/amount/how long:
Have you ever been exposed to or infected with:
- Gonorrhea
- Hepatitis
- HIV
- Syphillis
REVIEW OF SYSTEMS
Do you currently or have you ever had any problems in the following areas?
Constitutional
Fever, Weight Loss/Gain
- No
- Yes
Integumentary (Skin)
- No
- Yes
Neurological
Headaches
- No
- Yes
Migraines
- No
- Yes
Seizures
- No
- Yes
Eyes
Loss of Vision
- No
- Yes
Blurred Vision
- No
- Yes
Distorted Vision/Halos
- No
- Yes
Loss of Side Vision
- No
- Yes
Double Vision
- No
- Yes
Dryness
- No
- Yes
Mucous Discharge
- No
- Yes
Redness
- No
- Yes
Sandy or Gritty Feeling
- No
- Yes
Itching
- No
- Yes
Burning
- No
- Yes
Foreign Body Sensation
- No
- Yes
Excess Tearing/Watering
- No
- Yes
Glare/Light Sensitivity
- No
- Yes
Eye Pain or Soreness
- No
- Yes
Chronic Infection, Eye or Lid
- No
- Yes
Sties or Chalazion
- No
- Yes
Flashes/Floaters in Vision
- No
- Yes
Tired Eyes
- No
- Yes
Endocrine
Thyroid/Other Glands
- No
- Yes
Elevated Cholesterol
- No
- Yes
Cancer
- No
- Yes
Ears, Nose, Mouth, Throat
Sinus Congestion
- No
- Yes
Runny Nose
- No
- Yes
Post-Nasal Drip
- No
- Yes
Chronic Cough
- No
- Yes
Dry Thoat/Mouth
- No
- Yes
Allergies/Hay Fever
- No
- Yes
Respiratory
Asthma
- No
- Yes
Chronic Bronchitis
- No
- Yes
Emphysema
- No
- Yes
Vascular/Cardiovascular
Diabetes
- No
- Yes
Heart Pain
- No
- Yes
High Blood Pressure
- No
- Yes
Vascular Disease
- No
- Yes
Gastrointestinal
Diarrhea
- No
- Yes
Constipation
- No
- Yes
Genitourinary
Genitals/Kidney/Bladder
- No
- Yes
Bones/Joints/Muscles
Rheumatoid Arthritis
- No
- Yes
Muscle Pain
- No
- Yes
Joint Pain
- No
- Yes
Lymphatic/Hematologic
Anemia
- No
- Yes
Bleeding Problems
- No
- Yes
Allergic/Immunologic
Allergic/Immunologic
- No
- Yes
Psychiatric
Psychiatric
- No
- Yes
If you answered Yes to any of the above or have a condition not listed, please explain and list medications:
Patient Signature
Date
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

Patient History Form

Patient Information

Medical History

Family History

Social History

REVIEW OF SYSTEMS

Constitutional

Neurological

Eyes

Endocrine

Ears, Nose, Mouth, Throat

Respiratory

Vascular/Cardiovascular

Gastrointestinal

Genitourinary

Bones/Joints/Muscles

Lymphatic/Hematologic

Allergic/Immunologic

Psychiatric

Eye Doctor in San Jose

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