Electronic Patient Form

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Lakeshore Eyecare Center Patient History Form

Thank you for choosing Lakeshore Eyecare Center. To save yourself time in the office, please complete the below form and submit it electronically.

Please select the location of your appointment *

HollandHamilton

Name *

Address *

City *

State *

Zip Code *

Birthdate (XX/XX/XXXX) *

SSN

Gender *

Marriage Status: *

Email Address *

Home Phone Number: *

Alternate Phone Number:

Work Cell

Person Responsible for Payment and Relationship *

Occupation *

Employer *

Vision Insurance

Medical Insurance

Personal Eye-Vision Information

Have you had any serious eye injuries/surgeries? *

If yes, please explain.

Do you have:

Glaucoma? *

Retinal Degeneration? *

Cataracts? *

If yes, please explain.

At what age did you first begin to wear glasses?

What are your special vision activities? (example: reading, computer, hobbies etc...) *

Personal Medical Information

Primary Care Doctor: *

Please note any history for the following conditions:

Ear/Nose/Throat *

Heart/Circulation/BP *

Lungs/Breathing *

Immunity *

Digestive *

Constitutional *

Muscles/Joints *

Skin Problems *

Allergy *

Mental *

Neurological *

Genitourinary *

Are you Diabetic *

If yes, please explain, and include when you were first diagnosed.

List all medications you take. *

Do you have drug allergies? *

If yes, to what?

Have you ever experienced head trauma? *

If yes, please explain.

Do you use tobacco products? *

Do you use alcohol? *

Other? *

Family Medical Information

Please note any family history for the following conditions:

Hypertension *

Diabetes *

Stroke *

Thyroid *

Glaucoma *

Macular Degeneration *

Strabismus/Lazy Eye *

"Strong Glasses" *

Enter the verification code in the box below.

Verification Code: *

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