New Patient Form - Please fill out each tab

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
SS# _ _ _ -_ _ -_ _ _ _ Email
DOB mm/dd/yyyy Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Misc/Guardian
Billing Information Check Here if the Billing Address is the Same as Above
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Vision Insurance

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
If you are NOT the Primary on this insurance, please check this box and complete the following:
Primary Insured's Information
Name:Last, First MI
DOB mm/dd/yyyy
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Employer/School:
Your Relationship to Insured:Spouse Child Other

Medical Insurance

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
If you are NOT the Primary on this insurance, please check this box and complete the following:
Primary Insured's Information
Name:Last, First MI
DOB mm/dd/yyyy
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Employer/School:
Your Relationship to InsuredSpouse Child Other

Medical History

  Welcome to Insight Eyecare & Eyewear-Please fill out all applicable fields
Section 1 - VISUAL HISTORY:
Briefly describe the main reason for having an examination today: 

Other eye issues or problems?


Please list all eyedrops you use (OTC and Rx):
 How often used?:
 How often used?:
 How often used?:
 How often used?:

Are you currently experiencing any of the following? SET ALL TO NO

YES NO
Headaches
Blurred Vision
Double Vision
Eyes "hurt" or "tired"
Eye pain or soreness
Halos around lights
Bothered by light/sun light
Frequent styes
Eyes frequently red
Infection of eye or lid
Itchy Eyes
Burning Eyes
Watery Eyes
Dry Eyes
Eyes feel sandy/gritty
Mucous Discharge
Floaters
Loss of vision
Flashing lights

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you have a history of any of the following? SET ALL TO NO

YES NO
Blindness
Eye Turn (Strabismus)
Lazy Eye (Amblyopia)
Keratoconus
Glaucoma
Cataracts
Macular Degeneration
Retinal Detachment

 

 

 

 

 

 

 

 

Other eye disease or condition: 
Describe any eye injuries: 
List any eye surgeries: 


How many hours a day do you use a computer? 
How far away from your eyes is your computer monitor? 
Describe any visual symptoms from computer use:


I currently wear glasses:  Full-time   Part-time  
If part-time, how often/when?


CONTACT LENS WEARERS:
I currently wear contacts:  Full-time  Part-time   Soft  Rigid Gas Permeable
If part-time, how often/when?
Contact Lens Wearers:
Current Brand:  
Are your lenses comfortable? Yes  No  
How old is your current pair?  
What is your replacement schedule?     What solution do you use?   


Section 2 - MEDICAL HISTORY / REVIEW OF SYSTEMS: 
Physician's Name:    Last Visit Date:   
List all medications you are currently taking (including any OTC/vitamins):
List any medications you are allergic to:
Are you pregnant or nursing? Yes    No    If yes, what is the due/birth date?   

Have you ever experienced problems in the following areas? 
CONSTITUTIONAL None NEUROLOGICAL None RESPIRATORY None
Fever   Headaches   Asthma  
Weight Loss   Migraines   COPD  
Other   Stroke   Emphysema  
CARDIOVASCULAR None Multiple Sclerosis   Lung Cancer  
High Blood Pressure   Alzhiemer's   MUSKULOSKELETAL None
Cholesterol   Parkinson's   Rheumatoid Arthritis  
Heart Disease   IMMUNOLOGY/ALLERGY None Osteoporosis  
Heart Failure   HIV   Fibromyalgia  
Arrhythmias   Allergy to Metals   ENDOCRINE None
Vascular Disease   PSYCHIATRIC None Diabetes  
GASTROINTESTINAL None Anxiety   Thyroid Dysfunction  
Ulcers   Depression   Pituitary Dysfunction  
Intestinal Polyps   Drug Dependence   HEMATOLOGIC/BLOOD None
Reflux Disease   Alcoholism   Anemia  
Cancer   Bipolar or Schizophrenia   Bleeding Disorder  
INTEGUMENTARY (SKIN) None EARS/NOSE/THROAT None Other  
Rosacea   Allergies   GENITOURINARY None
Psoriasis   Sinus Congestion   Urinary Tract Infection  
Skin Cancer   Dry Mouth/Throat   Renal (Kidney) Failure  
    Hearing Loss   Prostate/Ovarian Cancer  
List any other diseases here: 

FAMILY HISTORY
Family history is unknown/adopted
Any history of the following in any family members (parents, grandparents, siblings, children)? 

  YES NO RELATIONSHIP TO PATIENT    YES NO RELATIONSHIP TO PATIENT 
Poor Vision       Cancer      
Blindness       Diabetes      
Eye turn (Strabismus)       High Blood Pressure      
Lazy Eye (Amblyopia)       Stroke      
Glaucoma       Thyroid Disease      
Cataracts       Other Inherited Disease     
Macular Degeneration      If yes, what disease? 

Retinal Detachment/Disease      

Section 4 - SOCIAL HISTORY (confidential)
How often do you smoke/use tobacco products? 
How often do you consume alcohol? 
Do you have? Hepatitis  HIV STDs None
Occupation:                Employer:


Section 5 - Who referred you to Insight Eyecare & Eyewear:   
If not referred, how did you hear about Insight Eyecare?                                                         

Submit Data

After completing all forms, please click on the "Submit Data" Final Tab at the top of this page.