Follow the steps to fill out the form seamlessly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your patient number in the designated field at the top of the form.
3. Fill in your personal information, including your name, address, birthdate, and contact information. Ensure that you enter accurate details to avoid any issues during your visit.
4. Select your gender and ethnicity/race from the options provided. This information helps the healthcare provider understand your background better.
5. Provide details about your employer, occupation, and hobbies. If you have no hobbies, check the box indicating none.
6. List any general health history by marking relevant health issues such as thyroid disease, allergies, or chronic conditions. Be thorough to ensure your optometrist has a complete understanding of your health.
7. Indicate your smoking status and specify the number of years if you smoke. If you do not smoke, check the relevant box.
8. Document your current medications and any allergies to medications. If you are not taking any medications, check the box for none.
9. Detail your personal eye history by marking known eye problems and indicating whether you wear glasses or contact lenses.
10. Provide your family health history by listing any known conditions and their relationships to you. This information can be crucial for assessing hereditary risks.
11. Fill out emergency contact, primary care physician information, and your insurance details.
12. State the main reason for your visit today as clearly as possible.
13. After completing the form, review all your entries for accuracy before proceeding to save changes, download, print, or share the form.

Complete your CA Simply Optometry Patient History Form online today for a smoother visit!