Don Holland, O.D.

Irvine Eye Care

14210 Culver Drive, Suite F

Irvine, CA 92604

Confidential Patient Information

***All sections must be completed in full to meet HIPAA compliance regulations.

Name (First, MI, Last):

Address:	City	State Zip

Home Phone:	Cell:	Work:

Email Address:	Birth Date:	Age:

Employer:	Occupation:

Person to contact in an emergency:	Phone:

Date of Last Exam:	Reason for Today’s Exam:

Insurance Information

Name of Primary Member:	Primary Member DOB:

Insurance Provider:	ID # of Primary Member:

Medical History

Do YOU have any history of the following?

⁭ Diabetes	⁭ Heart Condition ⁭ Macular Degeneration

⁭ High Blood Pressure	⁭ Cataract	⁭ Strabismus/Amblyopia (Turned/Lazy Eye)

⁭ Thyroid condition	⁭ Glaucoma	⁭ CHECK IF NONE APPLY

Please list all medications you are currently taking:

Are you allergic to medications? If so, please list:	If there are no changes to your medical or ocular history or medications, please initial here:

Do you currently wear glasses? ⁭ Yes	⁭ No

If so, when do you wear your glasses?

⁭ All the time	⁭ Reading/Near Work	⁭ Work Safety

⁭ Computer Work	⁭ Other (explain):

Do you currently wear contact lenses?	⁭ Yes	⁭ No

If no, are you interested in wearing contact lenses? ⁭ Yes	⁭ No

Have you had LASIK surgery? ⁭ Yes	⁭No

If no, are you interested in laser vision correction? ⁭ Yes	No

What hobbies or sports do you participate in?

X

Signature of Patient (or Parent if a Minor)	Date