Blaine Eye Clinic
(763)-757-7000

Patient Information Form

Completing and submitting the following information prior to your appointment will help us make your visit more punctual and thorough.

Office Location
Salutation Patient First Name Patient Middle Name Patient Last Name Suffix
Date of Birth Age Drivers License Number Issuing State Expires On
Address Apartment / Suite
City State Zip
Contact's Home Phone Mobile Phone Contact's Email
Is it ok to text you reminders regarding your appointment?


Patient Occupation Patient Employer Work Phone
Last 4 of Patient Social Security # Last 4 of Primary Insured Social Security #
Is this your first visit to our office? If yes, please tell us who referred you:

Please tell us the reason(s) for your upcoming visit: (Check all that apply)
Other, please explain:
Are you planning to get new contact lenses?

Are you planning to get new glasses at this visit?

Are you interested in LASIK ?


Insurance Information

Medical Insurance Company Medical Policy # Medical Group # Medicare #
Medical Insurance Company Medical Policy # Medical Group # Medicare #
Vision Insurance Company Vision Policy # Vision Group #

Medical History

To help our office better serve your specific needs, please check all that apply.
If response is No, leave boxes unchecked.

Eye History

Amblyopia (Lazy Eye) Double Vision Headaches
Blindness Drooping Eyelid Itching
Blurred Vision Distance Dryness Loss of Side Vision
Blurred Vision Near Excess Tearing / Watering Loss of Vision
Burning Eye Infection Mucous Discharge
Cataract(s) Eye Pain or Soreness Redness
Color Blindness Fluctuating Vision Retinal Detachment
Crossed Eyes Floaters or Spots Sandy or Gritty Feeling
Macular Degeneration Foreign Body Sensation Tired Eyes
Diabetic Retinopathy Glaucoma Other
Distorted Vision Glare/Light Sensitivity

General Health Condition

Please provide your family doctor's name, address and contact information:

Please check if you currently, or have ever had problems in the following areas:

AIDS / HIV Fever Rheumatoid Arthritis
Anemia Gastrointestinal Runny Nose
Bleeding Problems Genitals / Kidney / Bladder Sinus Congestion
Blood / Lymph Heart Disease Skin
Cancer High Blood Pressure Stroke
Cardiovascular Disease Joint Pain Thyroid Disease
Chronic Bronchitis Lupus Weight Loss
Chronic Cough Muscles / Bones / Joints Other System
Diabetes Neurological  
Dry Throat / Mouth Post-Nasal Drip  
Ears / Nose / Throat Pregnant or Nursing  
Emphysema Psychiatric  
Endocrine Respiratory (Asthma)
If you checked any boxes above, please explain:

Social History

This information is kept strictly confidential

Do you use tobacco products ? No Yes If yes, type/ amount/ how long:
Have you previously used tobacco ? No Yes If yes, how long ago:
Do you drink alcohol ? No Yes If yes, type/ amount/ how long:

Family History

Please check any family history (parents, grandparents, siblings) living or deceased for the following conditions:

Amblyopia (Lazy Eye) Diabetes Macular Degeneration
Blindness Glaucoma Retinal Detachment
Cancer Heart Disease Stroke
Cataract(s) High Blood Pressure Thyroid Disease
Color Blindness Kidney Disease Other
Crossed Eyes Lupus  

Currently taking medication(s) - prescription and / or over-the-counter

Select From List Or Type In Here...   Or Type In Here...
Reason:
Reason:
Reason:
Reason:
Reason:

If you take additional medications, please list them here:

Seasonal Allergies

Do You have Any Seasonal Allergies ? if Yes, Please Explain:


Drug Allergies

Do You have Any Drug Allergies ? if Yes, Please Explain:


We do verify both your general vision and medical insurance benefits prior to your appointment; however, it is important to remember all insurance plans are different and may not cover equally for certain procedures. We use the required insurance websites to verify benefits, but they do not include all details and changes associated with Obamacare. The insurance companies present the most accurate information possible with a disclaimer saying that they cannot guarantee accuracy. The patient and/or policy holder is ultimately responsible for all charges.

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