New Patient Form
Demographics
Patient Information
Title
First
Last
Mr.
Mrs.
Ms.
Dr.
Rev.
Fr.
Miss
Master
Address:
City:
State/ZipCode
TX
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
UT
VT
VI
VA
WA
WV
WI
WY
Cell Phone:
Email
Birthday
Sex
Male
Female
How did you hear about Mountain Eyeworks?
Family member
Insurance list
Coworker
Friend
Primary Care Doctor
Internet
Drove by
Other
Billing Address Is Different?
Billing Information
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Fr.
Miss
Master
Address
City
State
ZipCode
TX
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
UT
VT
VI
VA
WA
WV
WI
WY
Home Phone:
Work Phone:
After Completing All Forms Submit Data on Final Tab
Medical History
Eye History
Briefly Describe The Main Reason For Having An Examination Today:
Chief Complaint:
blurred vision distance
blurred vision near
blurred vision distance/near
headache
pain
watery
itch
redness
Floaters
HTN
Diabetic
AMD
Glaucoma
Cataract
F/U
Other
Associated: Do you have any other symptoms related to this?
none
dizzy
headache
loss of vision
blurred vision
Other
Other eye issues or problems
I currently wear glasses:
Full Time
Part Time
Other
If part-time, how often/when?
Occasionally
Driving
Reading / Computer
After contact lens removal
1-2 times per week
Half time
Sports
Weekends
Social activities
Other
I currently wear contacts:
Full Time
Part Time
No
If part-time, how often/when?
Occasionally
Driving
1-2 times per week
Half time
Sports
Weekends
Social activities
Other
Are your contact lenses comfortable?
Yes
No
Other
Contact Lens Type
Soft
Rigid
Hybrid
Other
Current Contact Lens brand, Right Eye:
Acuvue 1-day
Acuvue 1-day Moist
Acuvue 1-day Trueye
Acuvue 2
Acuvue Oasys
Acuvue Oasys for Astigmatism
Acuvue Oasys for Presbyopia
Acuvue Advance
Acuvue Advance for Astigmatism
Air Optix
Air Optix Night & Day
Air Optix Astigmatism
Air Optix Multifocal
Avaira
Biomedic Toric
Biomedic XC
Biofinity
Biofinity Toric
Biofinity Multifocal
Clearsight 1 day
Clearsight 1 day Toric
Focus Dailies Standard
Focus Dailies AC plus
Focus Dailies Toric
Frequency 55
Frequency 55 Toric
Frequency 55 Aspheric
Freshlook colorblends
Proclear
Proclear 1 day
Proclear EP
Proclear Multifocal
Purevision
Purevision 2
Purevision 2 Toric
Purevision Multifocal
Soflens 38
Soflens Toric
Soflens Daily Disposable
Soflens Multifocal
Vertex Toric
Boston EO
Boston ES
Boston XO
Fluoroperm 60
Menicon Z Thin
RGP - unknown material
Other
Current Contact Lens Brand, Left Eye:
Acuvue 1-day
Acuvue 1-day Moist
Acuvue 1-day Trueye
Acuvue 2
Acuvue Oasys
Acuvue Oasys for Astigmatism
Acuvue Oasys for Presbyopia
Acuvue Advance
Acuvue Advance for Astigmatism
Air Optix
Air Optix Night & Day
Air Optix Astigmatism
Air Optix Multifocal
Avaira
Biomedic Toric
Biomedic XC
Biofinity
Biofinity Toric
Biofinity Multifocal
Clearsight 1 day
Clearsight 1 day Toric
Focus Dailies Standard
Focus Dailies AC plus
Focus Dailies Toric
Frequency 55
Frequency 55 Toric
Frequency 55 Aspheric
Freshlook colorblends
Proclear
Proclear 1 day
Proclear EP
Proclear Multifocal
Purevision
Purevision 2
Purevision 2 Toric
Purevision Multifocal
Soflens 38
Soflens Toric
Soflens Daily Disposable
Soflens Multifocal
Vertex Toric
Boston EO
Boston ES
Boston XO
Fluoroperm 60
Menicon Z Thin
RGP - unknown material
Other
What solution do you use?
None
Optifree Replenish
Optifree Pure Moist
Optifree Express
Renu
Biotrue
Clear Care
Kirkland Signature
Revitalens
Generic store brand
Boston Advance
Boston original
Optimum
B & L Gas Perm
Unique Ph
Other
What is your replacement schedule?
Daily
Weekly
Every 2 weeks
Monthly
If they feel bad
Quarterly
Yearly
Other
How old is your current pair?
new
1-2 weeks
2-4 weeks
very old
Other
Average Wear Time:
1 - 3 Hours
4 - 7 Hours
8 - 10 Hours
All day
Occ. Overnight
Extended
Other
Days/Wk?
1
2
3
4
5
6
7
Other
Wear Schedule:
Part time
Daily wear
Flex wear
Weekly extended wear
Monthly extended wear
Other
If part-time, how often/when?
Occasionally
Driving
1-2 times per week
Half time
Sports
Weekends
Social activities
Other
Are your contact lenses comfortable?
Yes
No
Other
Contact Lens Type
Soft
Rigid
Hybrid
Other
Current Contact Lens brand, Right Eye:
Acuvue 1-day
Acuvue 1-day Moist
Acuvue 1-day Trueye
Acuvue 2
Acuvue Oasys
Acuvue Oasys for Astigmatism
Acuvue Oasys for Presbyopia
Acuvue Advance
Acuvue Advance for Astigmatism
Air Optix
Air Optix Night & Day
Air Optix Astigmatism
Air Optix Multifocal
Avaira
Biomedic Toric
Biomedic XC
Biofinity
Biofinity Toric
Biofinity Multifocal
Clearsight 1 day
Clearsight 1 day Toric
Focus Dailies Standard
Focus Dailies AC plus
Focus Dailies Toric
Frequency 55
Frequency 55 Toric
Frequency 55 Aspheric
Freshlook colorblends
Proclear
Proclear 1 day
Proclear EP
Proclear Multifocal
Purevision
Purevision 2
Purevision 2 Toric
Purevision Multifocal
Soflens 38
Soflens Toric
Soflens Daily Disposable
Soflens Multifocal
Vertex Toric
Boston EO
Boston ES
Boston XO
Fluoroperm 60
Menicon Z Thin
RGP - unknown material
Other
Current Contact Lens Brand, Left Eye:
Acuvue 1-day
Acuvue 1-day Moist
Acuvue 1-day Trueye
Acuvue 2
Acuvue Oasys
Acuvue Oasys for Astigmatism
Acuvue Oasys for Presbyopia
Acuvue Advance
Acuvue Advance for Astigmatism
Air Optix
Air Optix Night & Day
Air Optix Astigmatism
Air Optix Multifocal
Avaira
Biomedic Toric
Biomedic XC
Biofinity
Biofinity Toric
Biofinity Multifocal
Clearsight 1 day
Clearsight 1 day Toric
Focus Dailies Standard
Focus Dailies AC plus
Focus Dailies Toric
Frequency 55
Frequency 55 Toric
Frequency 55 Aspheric
Freshlook colorblends
Proclear
Proclear 1 day
Proclear EP
Proclear Multifocal
Purevision
Purevision 2
Purevision 2 Toric
Purevision Multifocal
Soflens 38
Soflens Toric
Soflens Daily Disposable
Soflens Multifocal
Vertex Toric
Boston EO
Boston ES
Boston XO
Fluoroperm 60
Menicon Z Thin
RGP - unknown material
Other
What solution do you use?
None
Optifree Replenish
Optifree Pure Moist
Optifree Express
Renu
Biotrue
Clear Care
Kirkland Signature
Revitalens
Generic store brand
Boston Advance
Boston original
Optimum
B & L Gas Perm
Unique Ph
Other
What is your replacement schedule?
Daily
Weekly
Every 2 weeks
Monthly
If they feel bad
Quarterly
Yearly
Other
How old is your current pair?
new
1-2 weeks
2-4 weeks
very old
Other
Average Wear Time:
1 - 3 Hours
4 - 7 Hours
8 - 10 Hours
All day
Occ. Overnight
Extended
Other
Days/Wk?
1
2
3
4
5
6
7
Other
Wear Schedule:
Part time
Daily wear
Flex wear
Weekly extended wear
Monthly extended wear
Other
Do
you
have a history of any of the following vision conditions?
All No
Blindness
Yes
No
Other
Eye Turn (Strabismus)
Yes
No
Other
Lazy Eye (Amblyopia)
Yes
No
Other
Keratoconus
Yes
No
Other
Glaucoma
Yes
No
Other
Cataracts
Yes
No
Other
Macular Degeneration
Yes
No
Other
Retinal Detachment
Yes
No
Other
Other eye disease or condition
Yes
No
Other
Headaches
Yes
No
Other
Are You Pregnant Or Nursing?
Yes
No If Yes, What Is The Due/Birth Date?
Are you currently experiencing any of the following vision-related symptoms?
All No
Blurred Vision
Yes
No
Other
Double Vision
Yes
No
Other
Eyes "hurt" or "tired"
Yes
No
Other
Halos around lights
Yes
No
Other
Bothered by light / sun light
Yes
No
Other
Frequent styes
Yes
No
Other
Eyes itch
Yes
No
Other
Eyes burn
Yes
No
Other
Eyes tear
Yes
No
Other
Eyes feel dry
Yes
No
Other
Eyes feel sandy/gritty
Yes
No
Other
Frequent Styes
Yes
No
Other
Flashing lights
Yes
No
Other
Floaters
Yes
No
Other
Describe any eye injuries:
none
Other
List any eye surgeries:
none
Other
How many hours a day do you electronic devices?
<2 hours
2 - 4 hours
5 - 8 hours
9 - 12 hours
12+ hours
Other
Describe any visual symptoms from electronic devise use:
none
Eye strain
Blurred vision
Headache
Dry eyes
Watery
Itch
Burn
Double vision
Other
Family History
All No
Poor Vision / Legally Blind?
Yes
No
Other
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Other
Blindness
Yes
No
Other
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Other
Eye turn (Strabismus)
Yes
No
Other
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Other
Lazy Eye (Amblyopia)
Yes
No
Other
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Other
Glaucoma
Yes
No
Other
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Other
Cataracts
Yes
No
Other
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Other
Macular Degeneration
Yes
No
Other
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Other
Retinal Detachment/Disease
Yes
No
Other
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Other
Cancer
Yes
No
Other
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Other
Diabetes
Yes
No
Other
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Other
High Blood Pressure
Yes
No
Other
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Other
Stroke
Yes
No
Other
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Other
Thyroid Disease
Yes
No
Other
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Other
Heart Disease
Yes
No
Other
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Other
Any other disease(s)?
Social History
How often do you smoke/use tobacco products?
No
Daily
Ocasionally
Rarely
Other
How often do you consume alcohol:
No
Daily
Ocasionally
Rarely
Other
Medical History
Physician's Name:
List all medications you are currently taking (including any OTC/vitamins):
Last Visit Date:
List any medications you are allergic to:
Preferred Pharmacy
Please list all eyedrops you use (OTC and Rx):
How often used?:
daily
occasionally
rarely
Other
Do you have any of the following
chronic
conditions?
All No
Migraines
Yes
No
Other
Multiple Sclerosis
Yes
No
Other
Thyroid
Yes
No
Other
Diabetes
Yes
No
Other
Type
Type 1
Type 2
Other
HbAIC
Diabetes last tested
< 6 months
> 6 months
Unknown
Other
Arthritis
Yes
No
Other
Allergies/Hay fever
Yes
No
Other
Asthma
Yes
No
Other
Emphysema
Yes
No
Other
High blood pressure
Yes
No
Other
High Cholesterol
Yes
No
Other
Stroke
Yes
No
Other
Anemia
Yes
No
Other
Cancer
Yes
No
Other
After Completing All Forms Submit Data on Final Tab
Submit Data
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