Eyecare Professionals Logo

Demographics

General Information
Title First Last MI Suffix Nickname
Address:
City: State/ZipCode
Appointment confirmations, office updates and billing are done through email & text only. Please make sure both are correct.
Cell Phone: Email
SSN Occupation
Birthdate Employment Status Employed Full-Time Student Part-Time Student
Sex Male Female Employer/School Name
Marital Status
Emergency contact name & phone number
Billing Information Is The Billing Address the Same?
Title First Last MI Suffix
Address

City State ZipCode
Home Phone:
Work Phone:

Primary

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name: Last, First MI
Relationship to Insured: Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name: Last, First MI
Relationship to Insured: Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

Please answer the following to allow us to serve you better Are you currently having any vision problems? If yes, Explain:
Reason for visit?

Are you thinking about getting new glasses today? Do you wear contact lenses?
Primary Medical Physician:
Do you smoke: Authorization & Release (HIPAA & ABN)Initial
Race: Ethnicity: Preferred Language:
Please list your Prescription Medications: No current Medications

Please list your Drug Allergies: No known drug Allergies

List your Over The Counter medications:
REVIEW OF OCULAR SYSTEM Select any conditions you may have:
Last Eye Exam: Who was the doctor? Current Eye Medications:
FAMILY OCULAR HISTORY (please select if any family member has the condition below)
Crossed/Lazy Eyes: Retinal Detachment: Macular Degeneration:
Cataracts: Glaucoma:
Family History (IS THIS REDUNDANT?) SET ALL TO NO
CONDITION RELATIONSHIP TO YOU
BLINDNESS No Yes
GLACOMA No Yes
CATARACTS No Yes
MACULAR DEGENERATION No Yes
DIABETES No Yes
HYPERTENTION No Yes
CANCER No Yes
HEART DISEASE No Yes
AMBLYOPIA (LAZY EYE) No Yes
STABISMUS (CROSSED EYES) No Yes
RETINAL DETACHMENT No Yes
OTHER No Yes
Current Eyewear Primary vision correction:
Type of Contacts worn?
REVIEW OF SYSTEMS DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS? SET ALL TO NO
CONSTITUTIONAL: Fever, weight loss, weight gain, fatigue? No Yes
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat No Yes
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease No Yes
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD No Yes
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux No Yes
GENITONURINARY: Kidney Stones, Frequent Urination, impotence No Yes
MUSCULOSKELETAL: Arthritis, Joint Pains, Head or Neck Injury No Yes
INTEGUMENTARY: growths, rashes, acne No Yes
PSYCHIATRIC: Depression, Anxiety, Insomnia No Yes
ENDORCRINE: Thyroid, Diabetes No Yes
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus No Yes
HEMATOLOGIC/LYMPHATIC: Anemia, cholesterol, bleeding problems No Yes
NEUROLOGICAL: Headaches, migraines, seizures No Yes

Injuries, Surgeries, Hospitalization:

Please list any additional notes:
SOCIAL HISTORY
Tobacco: Type: How Long:
Alcohol: Type: How Long:
Do you drive? If Yes, do you have difficulty driving at night?
What are your leisure activities?

Submit Data

Are you sure all of the information you gave us is correct? If so, please click Submit Data below.

Please bring your driver lincense, all your insurance cards, and any glasses you wear to your appointment.

After Completing All Forms Submit Data on Final Tab