Poulsbo Eyecare Center - New Patient Forms

Demographic Information

Patient Information Legal First Name

Legal Last Name

Suffix

Preferred Name (if different)

Birthdate

Social Security Number

Birth Sex: Male Female

Preferred Pronouns

Occupation

Hobbies

Contact Information Cell Phone #

Home Phone #

Other Phone #

E-mail Address

Mailing Address

City

State

Zip Code

Billing Address is Different

Insurance Information

Ameritas, Delta Vision, Guardian, MetLife Vision, and Principal Insured members - please choose "Vision Service Plan" as your plan name.

If you do not see your insurance plan listed, we may not be able to bill for your visit. Please contact the billing office at 360-779-2336, option 3, for more information.

Primary Vision Plan Plan Name

Member/Policy ID

Patient is not the primary subscriber

Secondary Vision Plan Plan Name

Member/Policy ID

Patient is not the primary subscriber

Primary Medical Plan Plan Name

Member/Policy ID

Patient is not the primary subscriber

Secondary Medical Plan Plan Name

Member/Policy ID

Patient is not the primary subscriber

Medical & Vision History

Current Vision & Eye Health What is the primary reason for your visit?

Do you wear glasses?

All the time Driving Occasionally Watching TV Reading Computer
Do you wear contact lenses?

Please list any eye drops or medications you are currently taking:

Eye Symptoms

Dryness
Itching
Burning
Watery/Tearing
Discharge/Crusting
Redness
Pain
Strain/Pulling
Sandy/Gritty Feeling
Eyelid droop
Eyelid twitching

Vision Symptoms

Blurred Vision (Distance)
Blurred Vision (Near)
Double vision
Poor night vision
Light Sensitive
Floaters
Flashing lights
Glare/Halos

Current & Past Eye History When was your last eye exam?

Last Eye Doctor

Eye/Vision Problem List

Cataracts:

Corneal Disease:

Crossed/Lazy Eye:

Eye Infections:

Eye Injury/Trauma:

Glaucoma:

Macular Degeneration:

Retinal Disease/Detachment:

Temporary Vision Loss:

Past Eye Treatments

Cataract Surgery
Corneal Surgery (RK, PRK, LASIK)
Glaucoma Surgery
Injections for Macular Degeneration
Retinal Surgery
Strabismus/Eye Muscle Surgery

Current & Past Medical History When was your last medical exam?

Primary Care Physician

Current & Past Medical Conditions

Allergies:

Anxiety or Depression:

Arthritis/Autoimmune Disease:

Asthma/Lung Disease:

Cancer:

Diabetes:

Last A1C:
Heart Attack:

Heart Disease:

High Blood Pressure:

High Cholesterol:

HIV / AIDS:

Kidney Disease:

Migraine Headaches:

Pregnant/Nursing (Currently):

Premature Birth:

Shingles:

Stroke:

Thyroid Disease:

Current Medications

No Current Medications
Drug Allergies

No Known Drug Allergies
Injuries, Surgeries, Hospitalizations

Tobacco Use

Family Medical & Eye History Macular Degeneration:

Glaucoma:

Cataracts:

Retinal Detachment:

Crossed/Lazy Eye:

Corneal Disease:

Family Medical History

Is there any family history (parent, sibling, grandparent) of: Diabetes, High Blood Pressure, Heart Disease, Cancer, Arthritis, Lupus, or Kidney Disease? If so, please specify below:

Online Patient Forms

Demographic Information

Insurance Information

Medical & Vision History