Follow the steps to successfully complete your patient history form.

1. Press the ‘Get Form’ button to access the CA Simply Optometry Patient History Form and open it for editing.
2. Begin by entering your patient number in the designated field at the top of the form. This is followed by your last name and first name to help identify your record.
3. Fill in the date of completion using the format MM/DD/YYYY. Next, provide your date of birth in the same format.
4. Complete your address section including city, state, and zip code. Make sure to enter accurate information to facilitate communication.
5. Enter your Social Security Number in the specified section. This is important for your health records.
6. Provide your primary phone number and occupation in the respective fields.
7. Fill in your email address and marital status. This information is crucial for record-keeping and contact.
8. List your hobbies and indicate your race/ethnicity as well as preferred language.
9. Select your preferred contact method from the options provided: email, mail, or phone.
10. Indicate who referred you to the optometry practice, if applicable.
11. In the general health history section, check all relevant health issues and provide additional details as necessary, including any existing medical conditions.
12. Document your eye and vision history, including any previous eye-related issues and relevant surgeries.
13. Indicate whether you wear glasses or contacts, along with the respective prescription details and how you use them.
14. List any medications you are currently taking and note any known allergies.
15. Update your smoking status and specify the number of years you have smoked, if applicable.
16. Fill out your family health history, providing relationships to any known conditions.
17. Enter the details of your emergency contact, primary doctor, and pharmacy, including their phone numbers.
18. Finally, provide your vision and health insurance details. Review all entered information for accuracy before submitting.
19. Once you have filled in all the required fields, you can save changes, download, print, or share the completed form as needed.

Complete your CA Simply Optometry Patient History Form online today to ensure effective eye care.