Adult History Form

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Provide the Following Information. Required Fields are bold.
Date
Patient name
Email Address e.g. someone@domain.com	^[_\.0-9a-zA-Z-]+@([_\.0-9a-zA-Z-]+\.)+[a-zA-Z]{2,8}$
Address
Address
City
State/Province
Zip/Postal Code
Home phone	( ^[0-9]+$ ) ^[0-9]+$ - ^[0-9]+$
Work phone	( ^[0-9]+$ ) ^[0-9]+$ - ^[0-9]+$
Who referred you to our office? (name)
How did you hear about us?
Patient's date of birth
Social security number	^[0-9]+$ - ^[0-9]+$ - ^[0-9]+$
Occupation
Name of employer
City
Special visual demands (work or hobbies)
Name of spouse
Please list any members of your household who come to our office
Please select if you have had any of the following	Mac Users - Select Multiple Fields with Command + Click PC Users - Select Multiple Fields with CTRL + Click
List any other medical problems
Who is your family physician?
Have you ever had any injury or surgery to your eyes?	Yes No
If yes, please describe
Have any blood line relatives had glaucoma, or other loss of sight?	Yes No
Are you allergic to any medications?	Yes No
If yes, please list
Do you presently wear glasses?	Yes No
How old are the glasses?
When do you wear them?
Do you presently wear contact lenses?	Yes No
What kind of contact lenses?
If yes, how old are the contacts?
If no, have you ever worn contacts?
Do you have vision care insurance?	Yes No
If yes, Name and ID number
Do you have health insurance?	Yes No
If yes, Name and ID number