Franklin Family Eyecare - New Patient Form

Demographics

TitleFirstLastMISuffixNickname
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?
TitleFirstLastMISuffix
Address

CityStateZipCode
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

Submit Data

After Completing All Forms Submit Data on Final Tab