EyeQ Optometry â New Patient Form

Demographics

How did you hear about us?

Title

First Name *

Last Name *

MI

Suffix

Nickname

Date of Birth (MM/DD/YYYY)

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Cell Phone *

Work Phone

Other Phone

Email Address

Preferred Contact Method

SSN

Occupation

Sex

Male Female Other

Employment Status

Employed Full-Time Student Part-Time Student

Marital Status

Employer / School Name

Primary Care Doctor

Misc / Guardian

Preferred Language

Ethnicity

Race

Billing Information

Billing address is the same as above â copy automatically

Title

First Name

Last Name

MI

Suffix

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Work Phone

Insurance

Primary Insurance

Insurance Name

Insurance Plan

Insurance ID

Policy Group #

Not primary on account

Primary on Account

Name (Last, First, MI)

Relationship to Insured

Spouse Child Other

Sex

Male Female

Address

City

State

Zip

Phone

Birthday (MM/DD/YYYY)

SSN

Employer / School

Secondary Insurance

Insurance Name

Insurance Plan

Insurance ID

Policy Group #

Not primary on account

Primary on Account

Name (Last, First, MI)

Relationship to Insured

Spouse Child Other

Sex

Male Female

Address

City

State

Zip

Phone

Birthday (MM/DD/YYYY)

SSN

Employer / School

Vision Plan

Insurance Name

Insurance Plan

Insurance ID

Policy Group #

Not primary on account

Primary on Account

Name (Last, First, MI)

Relationship to Insured

Spouse Child Other

Sex

Male Female

Address

City

State

Zip

Phone

Birthday (MM/DD/YYYY)

SSN

Employer / School

Medical History

Chief Vision Concern for This Visit

Please describe your main reason for visiting today

Patient Medical History

List any systemic conditions (diabetes, hypertension, cancer, autoimmune disorders, etc.)

If diabetic â year diagnosed

Last A1C value

Injuries, Surgeries, Hospitalizations

Pregnant or Nursing?

Smoking Status

Alcohol Use

Primary Care Physician

Last PCP Visit

Medications & Allergies

Current Prescription Medications (include vitamins & OTC meds)

No current medications

Drug Allergies

No known drug allergies

Family Medical History

List any family systemic history (diabetes, hypertension, cancer, autoimmune disorders, etc.)

Review of Systems â Do you currently experience any of the following?

Describe or indicate "None" for each category.

General Fever, weight loss/gain, fatigue

Ear, Nose & Throat Allergies, sinus, cough, dry mouth/throat

Cardiovascular High BP, heart surgery, vascular disease

Respiratory Asthma, bronchitis, emphysema, COPD

Genital / Kidney / Bladder Kidney stones, frequent urination

Muscles, Bones & Joints Arthritis, joint pains, head/neck injury

Skin Growths, rashes, acne

Neurological Headaches, migraines, seizures

Psychiatric Depression, anxiety, insomnia

Endocrine Thyroid, diabetes

Blood / Lymph Anemia, cholesterol, bleeding problems

Allergic / Immunologic Seasonal allergies, rheumatoid, MS, lupus, HIV

Gastrointestinal Diarrhea, constipation, ulcer, reflux

Ocular History

Eye Health History

Indicate any of the following you have experienced: Amblyopia, Dry Eyes, Eye Injuries, Eye Surgery, Flashes of Light, Floaters, Strabismus, Cataracts, Glaucoma, Retinal Disorders

Current Eye Medications

Primary Vision Correction

Last Eye Doctor

Last Eye Exam

Contact Lens History

Current brand of contact lenses

Daily Wear Time

Disposal Schedule

Family Ocular History

List any family ocular history (cataracts, glaucoma, macular degeneration, retinal disorders, etc.)