Optometric Management Tip # 250   -   Wednesday, November 01, 2006
A Sample History Form

Tip number 248 generated a lot of interest in forms. I made the point of being careful not to require patients to complete so many forms that they become an annoyance, but many readers emailed and asked for sample forms. This is a good reminder that forms and questionnaires are indeed necessary and important administrative aids.

Patient Demographic and Brief History

I’ll share the history form that I use in my practice below. I recognize that eye care practitioners have different philosophies and preferences, so one form will not suit everyone, but this one was designed to meet my goal of making forms easy and quick for patients to complete. Sample Form

Date__________Welcome to Gailmard Eye Center

Mr. Mrs. Dr. Miss Ms. Rev.
Patient's name______________________________________________

Address________________________ City________________ State_______ Zip__________

Home Phone___________ Work Phone__________ E-mail address ____________________

How did you hear of our office? __________________________________________________

Referred by ________________________________ May we send a thank you note? Y   N

OR:   Insurance listing   Family member  Yellow pages  Physician / Eye Doctor  Ad

Patient's date of birth__________________ Social Security Number_____________________


Name of employer_________________________________ City_______________________

Special visual demands (work or hobbies)___________________________________________

Name of spouse___________________________________________________________________

Please list any members of your household who come to our office

Please circle if you have ever had any of the following:
Cataracts | Glaucoma | Lazy Eye | Diabetes | Macular degeneration | Eye infections
High blood pressure | Allergies

Do you smoke? Yes  No

List any other medical problems__________________________________________________

Who is your family physician?___________________________________________________

Have you ever had any injury or surgery to your eyes? Yes     No Describe_________________

Previous eye doctor____________________________________________________________

Have any blood line relatives had glaucoma, or other loss of sight?______________________

Are you allergic to any medications? Yes    No (List)__________________________________

Do you presently wear glasses? Yes No     How old are the glasses?________________

When do you wear them?_______________________________________________________

Do you presently wear contact lenses? Yes    No   If no, have you ever worn contacts? Y   N

Do you have vision care insurance? Yes    No    Name________________________________

Do you have health insurance? Yes No    Name and ID number________________________

Please note: Insurance may cover none or only part of your fees. If we do not accept direct payment from your insurance plan, you will pay our office at the time of service and submit your receipt for reimbursement from your insurance company. If your insurance does not pay as expected, you are ultimately responsible for all charges. We cannot be responsible if you are not eligible for benefits. We will be happy to assist you with your claims, please give any forms to the receptionist.

Best wishes for continued success,

Neil B. Gailmard, OD, MBA, FAAO
Chief Optometric Editor, Optometric Management