750 Irving San Francisco, California 94122 Inner Sunset, near Golden Gate Park and UCSF

Dr. Kurtbay Optometry

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(415) 759-5448

Patient Questionnaire

PATIENT HISTORY

Patient History Form

Biological Sex

Date of Birth

Pronoun

Full Legal Name

Preferred Name

Address

City, State

Zip Code

Employer

Occupation

Home Phone Number

Work Number

Cell Phone Number

Email

Preferred Contact Method

Emergency Contact Name/ Number

Date of Last Eye Exam

Reason For Today’s Visit

VISION INSURANCE INFORMATION

VISION INSURANCE INFORMATION

Vision Insurance Name

Subscriber's Full Legal Name

Subscriber's Date of Birth

MEDICAL HISTORY

MEDICAL HISTORY

How is your General Health?

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Do you have known problems with any of these systems? (Please select all that apply)

Eye

Y

N

Gastrointestinal

Y

N

Nervous

Y

N

Mental

Y

N

Ears/Nose/Throat

Y

N

Genitourinary

Y

N

Endocrine

Y

N

Cardiovascular

Y

N

Musculoskeletal

Y

N

Blood/Lymph

Y

N

Respiratory

Y

N

Integumentary (skin)

Y

N

Allergic/Immunologic

Y

N

Please Elaborate

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Please answer all that apply:

Diabetes

Y

N

Not sure

Type of Diabetes

1

2

Pre-Diabetic

Date of diagnosis

Most Recent Hemoglobin A1c

Most Recent Blood Sugar

Allergies

Y

N

What are you allergic to?

Symptoms

Medication Allergy

Y

N

Name of Medication

Symptoms

Frequent Headaches

Y

N

Please list any other medical conditions/issues

Current medication (s)

Have you had any operations?

Y

N

Which operations and when if any?

Do you use cigarettes/tobacco? (Including E-cigarettes)

Y

N

Alcohol

Y

N

Other substances

Name of family doctor

Date of last visit

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FAMILY HISTORY

Do you have Hypertension (High blood pressure)?

Y

N

Unsure

Relation

Do you have Macular Degeneration?

Y

N

Unsure

Relation

Do you have Glaucoma?

Y

N

Unsure

Relation

Do you have Cataracts?

Y

N

Unsure

Relation

PERSONAL EYE INFORMATION

PERSONAL EYE INFORMATION

Have you had any eye operations?

Y

N

Type and date

Have you had any eye injuries?

Y

N

Please describe the injury and when it happened

Dry Eyes?

Y

N

Blurred Vision?

Y

N

Please describe any other eye problems you may have

Do you wear glasses?

Y

N

What type of glasses?

Contact lenses?

Y

N

What type of contact lenses do you wear?

When do you wear contact lenses?

Are you interested in wearing contact lenses?

Y

N

Are you interested in Lasik refractive eye surgery?

Y

N

Unsure

What hobbies or sports do you participate in?

Whom may we thank for referring you to us?

Thank you for contacting us. Please remember to have the other forms submitted as well.

We look forward to your visit!

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Phone: (415) 759-5448

Address: 750 Irving San Francisco, California 94122 Inner Sunset, near Golden Gate Park and UCSF

Email: drkurtbay@gmail.com

Contact Us

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Dr. Kurtbay Optometry

750 Irving Street

San Francisco, CA 94122

(Phone) 415-759-5448

(Fax) 415-759-9399

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All places of contact (equipment, tools, pens, chairs, tables) are disinfected between each patient visit.
All interactions will be as touchless as possible.
All frames, including frames brought for adjustment, are washed with a disinfectant solution and soap.
Restrooms are currently unavailable due to higher transmission risk.
Masks are required at this office.
By signing this document, I understand Dr. Kurtbay Optometry is taking measures to mitigate the risks of infection and will not hold my doctor or office staff responsible if I contract Covid-19 or any other virus.

Print Patient Name

Relationship to Patient

Patient Birthday

Today's Date

Email Address

Thank you for contacting us.
We will get back to you as soon as possible.

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Business Hours

Monday: Closed
Tue - Fri: 9:00 am - 6:00 pm
Saturday: 9:00 am - 5:00 pm
Sunday: Closed

Visa Payment Accepted

MasterCard Payment Accepted

Discover Payment Accepted

American Express Payment Accepted

Cash Payment Accepted

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