Franklin Family Eyecare - New Patient Form

Demographics

Title First Last MI Suffix Nickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Primary Doctor Misc/Guardian
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:

Tertiary

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

VISUAL HISTORY:
Briefly describe the main reason for having an examination today:

Associated: Do you have any other symptoms related to this?

Other eye issues or problems

I currently wear glasses: Part-time Full-time
If part-time, how often/when?
I currently wear contacts: Part-time Full-time
If part-time, how often/when?
Contact lens wearers: Are your lenses comfortable? Yes No
Rigid Gas Permeable Soft
What solution do you use?
Current Brand:
What is your replacement schedule?
How old is your current pair? Please list all eyedrops you use (OTC and Rx):
How often used?

Do you have a history of any of the following? -
Blindness Yes No
Eye Turn (Strabismus) Yes No
Lazy Eye (Amblyopia) Yes No
Keratoconus Yes No
Macular Degeneration Yes No
Retinal Detachment Yes No
Glaucoma Yes No
Cataracts Yes No
Are you currently experiencing any of the following? -
Headaches Yes No
Blurred Vision Yes No
Double Vision Yes No
Eyes "hurt" or "tired" Yes No
Floaters Yes No
Flashing lights Yes No
Eyes feel sandy/gritty Yes No
Halos around lights Yes No
Bothered by light/sun Yes No
Frequent styes Yes No
Eyes frequently red Yes No
Eyes itch Yes No
Eyes burn Yes No
Eyes tear Yes No
Eyes feel dry Yes No

List any eye surgeries:
Other eye disease or condition:
Describe any eye injuries:
How many hours a day do you use a computer?
Describe any visual symptoms from computer use:

______________________________________________________________________________________________________________________________________________________
MEDICAL HISTORY / REVIEW OF SYSTEMS:
Physician's Name:
Last Visit Date:
List all medications you are currently taking (including any OTC/vitamins):

Allergies/Alerts:

Height Weight Are you pregnant or nursing? Yes No
If yes, what is the due/birth date?

Do you have, or ever had, any CHRONIC problems in the following areas? -
Migraines Yes No
Multiple Sclerosis Yes No
Diabetes Yes No
Thyroid problems Yes No
Arthritis Yes No
Allergies/Hay fever Yes No
Asthma Yes No
Emphysema Yes No
High blood pressure Yes No
Stroke Yes No
Anemia Yes No
Cancer Yes No
Notes:

______________________________________________________________________________________________________________________________________________________
FAMILY HISTORY Family history is unknown/adopted
Any history of the following in any family members (parents, grandparents, siblings, children)? -
Poor Vision Yes No   RELATIONSHIP TO PATIENT
Blindness Yes No   RELATIONSHIP TO PATIENT
Eye turn (Strabismus) Yes No   RELATIONSHIP TO PATIENT
Lazy Eye (Amblyopia) Yes No   RELATIONSHIP TO PATIENT
Glaucoma Yes No   RELATIONSHIP TO PATIENT
Cataracts Yes No   RELATIONSHIP TO PATIENT
Macular Degeneration Yes No   RELATIONSHIP TO PATIENT
Retinal Detachment/Disease Yes No   RELATIONSHIP TO PATIENT
Cancer Yes No   RELATIONSHIP TO PATIENT
Diabetes Yes No   RELATIONSHIP TO PATIENT
High Blood Pressure Yes No   RELATIONSHIP TO PATIENT
Stroke Yes No   RELATIONSHIP TO PATIENT
Thyroid Disease Yes No   RELATIONSHIP TO PATIENT
Other Inherited Disease Yes No   RELATIONSHIP TO PATIENT
If yes, what disease? ______________________________________________________________________________________________________________________________________________________
SOCIAL HISTORY (confidential)
How often do you smoke/use tobacco products?
How often do you consume alcohol:
Do you have? HIV Hepatitis STDs
Occupation: Employer:
______________________________________________________________________________________________________________________________________________________
Who referred you to our office?
If "other", please specify

Signatures and Submit Data

Contact Lens Compliance

Click here to read the Compliance form

I have read and understood all of the above instructions
Electronic Signature:


Contact Lens Fees

Click here to read the Contact Lens fees

I would like to have a contact lens evaluation today.

Initials

I do not want a contact lens evaluation today and I am aware that without it I will not get a prescripton for contact lenses.

Initials

Patient name: Date:

Electronic Signature of Responsible Party:

Notice of Franklin Family Eyecare Policies Relating to Patient Privacy

Click here to read the Privacy Policies

I, acknowledge that I have received a copy of the Patient Privacy Polcies of Franklin Family Eyecare

Electronic Signature: Date:

Optomap

Click here to read Optomap Information

I would like more information on the Optomap Retinal Imaging
I DO want Optomap retinal imagin and I understand that I am responsible for the $40.
I DO NOT want the Optomap retinal Imaging and prefer to have the dialation drops.

Electronic Signature: Date:

After Completing All Forms Submit Data on Final Tab