ENVISION OPTIQUE
Dr. Michael R. Obregon
Board Certified Optometric Physician

Please fill out this form as completely as possible. Once you have completed the form, click "Submit." Your information will be received securely and we'll have it ready when you come in.

GENERAL INFORMATION

Full Name:*

First Last

Sex:*

Male
Female

Date of Birth:*

Employer:*

Occupation:*

Primary Ph #:*

Secondary Ph #:*

Email Address:*

Preferred Method of Contact*

Phone
Text
Email

Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

MEDICAL HISTORY

Please list any medical conditions now or in the past:*

Please list current medications (including birth control, hormones, eye drops, supplements):*

Name of Primary Care Physician:*

Ph #:*

Date of Last Physical:*

MEDICAL SYSTEMS REVIEW*

If you selected "family" for any of the above conditions, please specify the condition and which family member below:

Condition	Family member

OCULAR HISTORY/SYMPTOMS*

If other, please specify:

Anything else we should know about?*

INSURANCE INFORMATION

VISION INSURANCE:

Name of Insurance:*

Policy / ID #:*

Are you the Primary Insured?*

Yes
No

If not Primary Insured – Name of Primary:

Relationship to Primary Insured:

MEDICAL INSURANCE:

Name of Insurance:*

Policy / ID #:*

Are you the Primary Insured?*

Yes
No

If not Primary Insured – Name of Primary:

Relationship to Primary Insured:

REASON FOR THE VISIT

Why are you here today?*

For example: contact lenses, eye problems, new glasses, routine exam, etc.

How did you hear about us?*

For example: insurance website, friend, family (please list name), social media, etc.

Does your work require special vision needs?*

Yes
No

Do you have persistent dryness in your eyes?*

Yes
No

Interested in corrective laser surgery?*

Yes
No

Interested in eliminating glasses without surgery?*

Yes
No

Hidden

Activities/ Hobbies require special vision needs?

Yes
No

Hidden

Are you interested in Contact lenses?

Yes
No

Hidden

Are you interested in corrective laser surgery?

Yes
No

	Yes	No	Family
Allergies
High Blood Pressure
Heart Disease
Diabetes
Gastrointestinal (Digest.)
Cancer
Endocrine/ Thyroid
Ear-Nose-Throat
Headaches
Urinary
Blood/ Lymph Nodes
Respiratory/ Lungs
Infectious

	Yes	No
Blurred Vision
Double Vision
Tired When Reading
Spots
Cataracts
Eyelid Problems
Glaucoma
Tearing
Surgery
Trauma
Heavy Computer Use
Active Sports / Hobbies
Other

Welcome Page – English

History Form - English - New Patient

GENERAL INFORMATION

MEDICAL HISTORY

INSURANCE INFORMATION

REASON FOR THE VISIT