Follow the steps to accurately complete the form.

1. Click the ‘Get Form’ button to obtain the form and access it in your editor.
2. In the first section, fill in your name, date of birth, and Social Security Number (SSN) accurately. Ensure that the name matches the identification documents.
3. Provide the name of your family physician. This may be required for coordination of your health care.
4. Indicate your marital status by selecting one of the following options: married (M), single (S), divorced (D), or widowed (W).
5. Next, fill in your occupation and indicate whether you work full-time (FT) or part-time (PT).
6. Record the date of your last eye health exam, which may assist in tracking your eye care history.
7. Proceed to the patient medical history section. For each listed condition (e.g., allergies, headaches, heart disease), select 'Yes' or 'No' based on your health status.
8. Continue through the history of health conditions, including immunologic, gastrointestinal, and psychiatric issues, responding to each with 'Yes' or 'No.'
9. If applicable, specify other health problems in the provided space.
10. Document your smoking habits by indicating whether you smoke and how much per day.
11. Fill out the ocular history section by stating whether you have experienced any related conditions or surgeries, answering 'Yes' or 'No.'
12. List all current medications, including any allergies to medications, ensuring thoroughness.
13. Complete the family history section by selecting 'Yes' or 'No' regarding the presence of conditions within your family.
14. In the authorization section, affirm that you understand and certify that the information provided is accurate.
15. Finally, sign and date the form to validate your submission. If you are a minor, a parent or guardian must sign.
16. After reviewing all entries for possible errors, save your changes, download the completed form, print it, or share it as necessary.

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