Get Eyes On J Patient History Questionnaire

Completing the Eyes on J Patient History Questionnaire online is a straightforward process that helps gather important information about your health history. This guide provides you with step-by-step instructions to ensure your experience is seamless and efficient.

Follow the steps to accurately complete your patient history questionnaire

1. Press the ‘Get Form’ button to access the patient history questionnaire and open it in your online document editor.
2. Fill in today's date at the top of the questionnaire for proper record-keeping.
3. Provide your personal information. Enter your full name, date of birth, age, and sex by selecting either 'M' for male or 'F' for female.
4. Complete your address details, including street, city, state, and zip code.
5. List your phone numbers, including home, work, and cell, and circle the number you prefer as your primary daytime contact.
6. If you wish to share your email address, which is optional, enter it in the provided space.
7. Indicate the person or source that referred you on the line provided.
8. Fill out your insurance information, including the primary subscriber's name and whether you have a vision plan.
9. Provide the primary subscriber's date of birth and the last four digits of their social security number.
10. Describe your general health in the designated space. This information helps the healthcare provider understand your medical background.
11. For each specified system, indicate whether you have any problems by circling 'yes' or 'no'. Provide explanations for any 'yes' responses.
12. Answer the diabetes screening question and specify the type and date of diagnosis if applicable.
13. List any allergies to medication and note the reactions. If there are no allergies, indicate this as well.
14. List your current medications or check the box if you have none.
15. Indicate whether you smoke, and if female, answer if you are pregnant or nursing.
16. Detail any past surgeries along with their dates.
17. Record the name of your family doctor, the date of your last visit, and when you received your last tetanus shot.
18. Provide your personal eye information, including the date of your last eye exam and whether you were dilated.
19. Answer history questions regarding eye conditions, injuries, surgeries, and any use of glasses or contact lenses.
20. Include information about your daily computer use and any eyestrain you experience.
21. Fill in family medical and eye health history, indicating any relevant conditions and the relation to you.
22. Once you have completed all sections of the questionnaire, you can save your changes, download, print, or share the completed form as needed.

Start filling out your Eyes on J Patient History Questionnaire online today!