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Located on the corner of S. Wayside and Jamil Medical Center right next to Fiesta. Walk-ins welcome.

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Home » INTAKE

INTAKE

Birth Date

MM slash DD slash YYYY

Appointment Date

MM slash DD slash YYYY

Patient's Name

First Last

M

F

Address

Street Address City ZIP / Postal Code Country

Cell Phone

Home Phone

Work Phone

Email

SS#

Employer/School

Occupation

Emergency Contact

Phone Number

Date of Last Eye Exam

MM slash DD slash YYYY

Name of Previous Eye Doctor

First Last

Medical Insurance

Vision Insurance

Who Recommended Us or Referred you?

what are Your Sports and Hobbies?

Personal Medical Information:Do you have a problem with any of these systems? If yes, please check box.

Gastrointestinal

Ear/Noseffilfoat

Cardiovascular

Respiratory

Headaches

Nervous System

Genitourinary

Musculoskeletal

Skin

Mental

Endocrine (Glands)

BloocVLymph

Allergic/Immunologic

Diabetes

Surgeties (what type & when)

Are you in good health?

Yes

No

Any allergic reactions to medications or other substances?

Yes

No

please list

Name of general physician

First Last

Please Check Yes or No

Do you smoke?

Yes

No

How much?

Do you drink alcohol?

Yes

No

How much?

Do you take medications?

Yes

No

Please list names & how often

Do you use other substances?

Yes

No

Do you have family history of any of the following? If yes, please check box.

Diabetes

Glaucoma

High blood pressure

Macular Degen.

Retinal Detachment

Cataracts

Please explain any boxes you have checked

Do you have any of the following? If yes, please check box

Dry Eyes

Eye Surgeries

Blurry Vision

Eye injrnies

Wear Glasses

Wear Contacts

Any eye problems at this time?

Yes

No

Please explain

Are you interested in laser vision correction?

Yes

No

Please sign below that you have reviewed all information tion above and it is coffect to the best of your knowledge.

Signature

Date

MM slash DD slash YYYY

Birth Date

MM slash DD slash YYYY

Appointment Date

MM slash DD slash YYYY

Patient's Name

First Last

M

F

Address

Street Address City ZIP / Postal Code Country

Cell Phone

Home Phone

Work Phone

Email

SS#

Employer/School

Occupation

Emergency Contact

Phone Number

Date of Last Eye Exam

MM slash DD slash YYYY

Name of Previous Eye Doctor

First Last

Medical Insurance

Vision Insurance

Who Recommended Us or Referred you?

what are Your Sports and Hobbies?

Personal Medical Information:Do you have a problem with any of these systems? If yes, please check box.

Gastrointestinal

Ear/Noseffilfoat

Cardiovascular

Respiratory

Headaches

Nervous System

Genitourinary

Musculoskeletal

Skin

Mental

Endocrine (Glands)

BloocVLymph

Allergic/Immunologic

Diabetes

Surgeties (what type & when)

Are you in good health?

Yes

No

Any allergic reactions to medications or other substances?

Yes

No

please list

Name of general physician

First Last

Please Check Yes or No

Do you smoke?

Yes

No

How much?

Do you drink alcohol?

Yes

No

How much?

Do you take medications?

Yes

No

Please list names & how often

Do you use other substances?

Yes

No

Do you have family history of any of the following? If yes, please check box.

Diabetes

Glaucoma

High blood pressure

Macular Degen.

Retinal Detachment

Cataracts

Please explain any boxes you have checked

Do you have any of the following? If yes, please check box

Dry Eyes

Eye Surgeries

Blurry Vision

Eye injrnies

Wear Glasses

Wear Contacts

Any eye problems at this time?

Yes

No

Please explain

Are you interested in laser vision correction?

Yes

No

Please sign below that you have reviewed all information tion above and it is coffect to the best of your knowledge.

Signature

Date

MM slash DD slash YYYY

Patient History Form - English

Formulario de historial del paciente - Español

Clara Vision

910 South Wayside Drive, #400
Houston, TX 77023

Phone: 713-921-0233

Monday: 10:00 AM - 5:00 PM
Tuesday: 10:00 AM - 5:00 PM
Wednesday: 10:00 AM - 5:00 PM
Thursday: 10:00 AM - 5:00 PM
Friday: 10:00 AM - 5:00 PM
Saturday: 10:00 AM - 4:00 PM
Sunday: Closed

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Privacy Policy

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Clara Vision - Located at 910 South Wayside Drive, #400, Houston, TX 77023. Phone: 713-921-0233 . https://www.claravision-optical.com

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