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Formerly The Stanwood Eye Clinic. Serving Stanwood and Camano Island for over 30 years

Located at 27101 Pioneer Hwy, Stanwood, WA

Call 360-629-9535

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Our Team
- Our Doctors
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Home » Contact Us » Patient History Form

Patient History Form

Name*
First Last
Date of Birth
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
HOME PHONE
WORK PHONE
CELL PHONE*
E-MAIL ADDRESS*
*
I attest that I have not had any symptoms or any exposure to anyone who has COVID- 19. I also accept the risk and consent to a visit today
Signature
Occupation
Employer
Family Doctor
Are you pregnant/nursing
- Yes
- No
What brought you in today
Are you interested in
- New spectacles
- Anti-Reflective lens
- Clip-ons
- Contact Lenses
- Lasik
- Safety glasses
- Light weight glasses
- Sunglasses
- Anti-fatigue/Blue light lens
Personal Eye History: Check all that apply
- Eye surgery
- Eye injury
- Wearing an eye patch
- Retinal detachment
- Lazy eye/eye turn
- Color blindness
- None
Review of Systems
check all that apply or check None
General Health*
- cancer
- fatigue
- developmental disabilities
- weight loss/gain
- None
Ear/Nose/Throat*
- cough
- hearing loss
- earache sinus congestion
- dry mouth
- sore throat
- None
Cardiovascular*
- pacemaker
- high blood pressure
- heart disease
- congestive heart failure
- None
Respiratory*
- asthma
- bronchitis
- emphysema
- COPD
- sleep apnea
- None
Gastrointestinal*
- GERD
- Crohn's
- gallbladder
- colitis
- ulcer
- acid reflux
- celiac
- None
Gastro-urinary*
- Bladder issues
- kidney disease
- prostate disease
- STD
- None
Muscle/Skeleton*
- back pain
- arthritis
- fibromyalgia
- gout
- muscular dystrophy
- None
Integumentary*
- itching
- eczema
- psoriasis
- rosacea
- cold sores
- shingles
- None
Neurological*
- seizures
- migraines
- stroke
- epilepsy
- cerebral palsy
- multiple sclerosis
- None
Psychological
- memory loss
- depression
- ADHD
- anxiety
- bipolar
- None
Endocrine*
- Diabetes Type I or II
- sweating
- hormonal dysfunction
- thyroid
- Hashimoto
- None
Lymphatic/Blood*
- anemia
- bleeding problems
- high cholesterol
- leukemia
- None
Allergies/Immune*
- environmental
- food
- Lupus
- Sjorgrens
- HIV
- autoimmune
- None
Do you currently take any medications? Please list and indicate dosage and frequency if known
None
Do you have any allergies to medications? Please list with reactions
None
Do you use OR have you ever used the following products
Tobacco*
- Yes
- No
- Previous
if yes indicate frequency/past use
Alcohol*
- Yes
- No
- Previous
if yes indicate frequency/past use
Other Drugs*
- Yes
- No
- Previous
if yes indicate frequency/past use
Family History (If yes, please indicate who in the family)
Macular Degeneration
who in the family
Glaucoma
who in the family
Cataracts
who in the family
Cancer
who in the family
High Blood Pressure
who in the family
Diabetes
who in the family
Thyroid
who in the family
Condition
who in the family
Cholesterol
who in the family
NONE
Please list any other condition you would like us to know about
How you were referred to us
- Insurance Company
- Yellow pages
- Another patient
- Internet search/website
- Social Media
- Newspaper/advertisement
Insurance Information
Insurance Provider*
Insurance ID Number*
Group Number*
Guarantor information required if under the age of 18
Please list who will be the guarantor for this account if patient is under the age of 18
Name Cell Phone Address (if different from patient)
Dilation
- I Authorize my child's eyes to be dilated
- I decline to have my child eyes dilated
Contact Lens Evaluation
Contact lens evaluations are $58-$128 depending on your prescription and the type of contact lens used to meet your needs.
- YES, I would like to update my CL prescription prescription at this time
- NO, I do not need a CL
The contact lens evaluation includes trial contact lenses, any neccessary follow up visits, as well as training needed to help insert and remove your contact lenses.

If you are a current contact lens wearer, a new evaluation is performed each time you are seen by a doctor.
Acknowledgement of Receipt of this Notice
This Practice is concerned about the privacy of our patient’s health care information. Our intent is to make you aware of the possible uses and disclosures of your protected health information and your privacy rights. The delivery of your healthcare services will in no way be conditioned upon your signed acknowledgement. If you decline to provide a signed acknowledgement, we will continue to provide your treatment and will use and disclose your protected health information for treatment, payment, and health care operations when necessary.
*
I acknowledge that I have received the Notice of Privacy Practices for Vision Plus.
Signature of patient/authorized representative
This field is hidden when viewing the form
Date
MM slash DD slash YYYY
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Patient History Form

Stanwood Office

27101 Pioneer Hwy,
Stanwood, WA 98292

Phone: 360-629-9535
Fax: 360-629-9536

Monday: 9:00 AM - 5:30 PM
Tuesday: 9:00 AM - 5:30 PM
Wednesday: 9:00 AM - 5:30 PM
Thursday: 9:00 AM - 5:30 PM
Friday: 9:00 AM - 5:30 PM
Saturday: Closed
Sunday: Closed

* We are closed between 1:00 PM -2:00 PM for lunch.

This fun, interactive tool uses questions about you, your lifestyle and your specific eyewear needs to generate eyewear suggestions specifically tailored to suit you!

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Contact Us
What’s New
Disclaimer
Privacy Policy

Hours & Location
Our Team
Eye Care Services
Eyeglasses & Contacts
Insurance Info

Hours & Location
Our Team
Eye Care Services
Eyeglasses & Contacts
Insurance Info

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Stanwood Eye Clinic - Located at 27101 Pioneer Hwy,, Stanwood, Washington 98292 Phone: 360-629-9535

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