Welcome Page – English History Form - English - New Patient 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 INFORMATIONFull 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country MEDICAL HISTORYPlease 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*YesNoFamilyAllergiesHigh Blood PressureHeart DiseaseDiabetesGastrointestinal (Digest.)CancerEndocrine/ ThyroidEar-Nose-ThroatHeadachesUrinaryBlood/ Lymph NodesRespiratory/ LungsInfectiousIf you selected "family" for any of the above conditions, please specify the condition and which family member below:ConditionFamily member OCULAR HISTORY/SYMPTOMS*YesNoBlurred VisionDouble VisionTired When ReadingSpotsCataractsEyelid ProblemsGlaucomaTearingSurgeryTraumaHeavy Computer UseActive Sports / HobbiesOtherIf other, please specify: Anything else we should know about?* INSURANCE INFORMATIONVISION 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 VISITWhy 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 HiddenActivities/ Hobbies require special vision needs? Yes No HiddenAre you interested in Contact lenses? Yes No HiddenAre you interested in corrective laser surgery? Yes No