New Patient Form

Demographics

* Indicates Required Field     ** Must Include Either Home or Cell Phone Title First* Last* MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev. Fr. Miss

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:
Other Phone:		Alerts:
Cell Phone**:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday*		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status*	Married Never Married Annulled Divorced Domestic Partner Interlocutory Legally Separated Polygamous Widowed (req by ins)	Employer/School Name
		Misc/Guardian

Billing Information

Is The Billing Address Different? Yes

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Fr. Miss

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:

Please fill out all tabs before submitting data.

Visual History

Briefly describe the main reason for having an examination today:

Do you have any other eye related problems?

When was your last eye exam?

I currently wear glasses:   Never  Full-time  Part-time     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

I currently wear contacts:  Never  Full-time  Part-time     If part-time, how often/when? Occasionally Driving 1-2 times per week Half time Sports Weekends Social activities

Contact Lens Wearers:
Are your contact lenses comfortable?  Yes No	Type of contact lenses worn:   Soft Rigid Gas Permeable
Current Brand:  Unknown Brand Acuvue 1-day Moist Acuvue 1-day Moist Astigmatism 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 Biomedic Toric Biomedic XC Biofinity Biofinity XR Biofinity Toric Biofinity Multifocal Biotrue ONEday Dailies Aqua Comfort Plus Dailies Aqua Comfort Plus Multifocal Dailies Aqua Comfort Plus Toric Dailies Total One Focus Dailies Standard Focus Dailies Toric Frequency 55 Frequency 55 Toric Frequency 55 Aspheric Freshlook Colorblends Hydrasoft Toric Proclear Proclear 1 day Proclear 1 day multifocal Proclear EP Proclear Multifocal Purevision Purevision 2 Purevision 2 Toric Purevision Multifocal Soflens 38 Soflens Toric Soflens Daily Disposable Soflens Multifocal Boston EO Boston ES Boston XO Boston XO2 RGP - unknown material	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

How often do you replace your contact lenses?   Daily Weekly Every 2 weeks Monthly If they feel bad Quarterly Yearly	How old is your current pair?  new 1-2 weeks 2-4 weeks very old
If no longer wearing contact lenses, why did you stop?

Do you have a history of any of the following?	Are you currently experiencing any of the following?
Y     N	Y     N

Blindness	Headaches	Eyes frequently red
Color Blindness	Blurred Distance Vision	Eyes itch

Eye Turn (Strabismus)	Blurred Near Vision	Eyes burn
Lazy Eye (Amblyopia)	Double Vision	Eyes tear

Keratoconus	Eyes "hurt" or "tired"	Eyes feel dry
Glaucoma	Halos around lights	Sandy / Gritty Eyes

Cataracts	Bothered by light / sun	Flashing lights
Macular Degeneration	Frequent styes	Floaters

Retinal Detachment	Eye Infection	Ptosis (Drooping Eyelids)
Other Eye Disease	Mucous Discharge	Loss of Side Vision

 

Describe any eye injuries or surgeries:             List any other surgeries:                                        Surgery Dates:

How many hours a day do you use a computer?  <2 hours 2 - 4 hours 5 - 8 hours 9 - 12 hours 12+ hours      Describe any visual symptoms from computer use:  none Eye strain Blurred vision Headache Dry eyes Watery Itch Burn Double vision

Please fill out all tabs before submitting data.

Medical History

Primary Care Physician's Name:       Last Visit Date

Preferred Pharmacy:

List all medications you are currently taking (including any OTC/vitamins):      List any medications you are allergic to:

Please list all eyedrops you use (OTC and Prescription) and how often you use them:

Do you have, or ever had any CHRONIC problems in the following areas?

Y     N	Y     N
Fever	Muscles, Bones, Joints (Arthritis, etc)
Weight Loss	Skin (Acne, Warts, Skin Cancer, etc)
Other Constitutional Symptoms	Neurological (Migraines, MS, Seizures, etc)
Ears, Nose, Throat	Psychiatric (Anxiety, Depression, Insomnia)
Cardiovascular (High BP, Heart, Vessels)	Endocrine (Diabetes, Thyroid, etc)
Respiratory (Asthma, Sleep Apnea, etc)	Blood / Lymph (Cholesterol, Anemia)
Gastrointestinal (Reflux, diarrhea, etc)	Allergic / Immunologic (Allergies, RA, etc)
Genital, Kidney, Bladder	Other
Are you pregnant or nursing? Yes No	If yes, what is the due/birth date?

Height:  ft  in                Weight:  lbs

If diabetic, what was your last HbA1c?

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Family and Social History

Family History         Family history is unknown/adopted

Any history of the following in any family members (parents, grandparents, siblings, children)?

Y    N	Relation to Patient	Y    N	Relation to Patient
Poor Vision	Mother Father Sibling Aunt Uncle Grandmother Grandfather	Arthritis	Mother Father Sibling Aunt Uncle Grandmother Grandfather
Blindness	Mother Father Sibling Aunt Uncle Grandmother Grandfather	Cancer	Mother Father Sibling Aunt Uncle Grandmother Grandfather
Eye turn (Strabismus)	Mother Father Sibling Aunt Uncle Grandmother Grandfather	Diabetes	Mother Father Sibling Aunt Uncle Grandmother Grandfather
Lazy Eye (Amblyopia)	Mother Father Sibling Aunt Uncle Grandmother Grandfather	Heart Disease	Mother Father Sibling Aunt Uncle Grandmother Grandfather
Glaucoma	Mother Father Sibling Aunt Uncle Grandmother Grandfather	High Blood Pressure	Mother Father Sibling Aunt Uncle Grandmother Grandfather
Cataracts	Mother Father Sibling Aunt Uncle Grandmother Grandfather	Kidney Disease	Mother Father Sibling Aunt Uncle Grandmother Grandfather
Macular Degeneration	Mother Father Sibling Aunt Uncle Grandmother Grandfather	Stroke	Mother Father Sibling Aunt Uncle Grandmother Grandfather
Retinal Detachment/Disease	Mother Father Sibling Aunt Uncle Grandmother Grandfather	Thyroid Disease	Mother Father Sibling Aunt Uncle Grandmother Grandfather
Color Blindness	Mother Father Sibling Aunt Uncle Grandmother Grandfather	Other Inherited Disease	Mother Father Sibling Aunt Uncle Grandmother Grandfather

Social History (confidential)
Smoking Status:	Never Smoker (<100 lifetime cigarettes) Former smoker (no longer smoke) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker, current status unknown Current everyday smoker Unknown if ever smoked
How often do you consume alcohol:	Never Occasionally Daily
Preferred Language:  English Spanish French Other	Race:  American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Prefer not to to Specify	Ethnicity:   Hispanic or Latino Not Hispanic or Latino Unknown Prefer not to Specify

Occupation:	Employer:

Hobbies / Interests?

What is the first and last name of the person who referred you to our office?	(for our referral program)
If not referred, how did you hear about Olympia Vision Clinic?	Family member Insurance list Coworker Friend Primary Care Doctor Internet Drove by

Please fill out all tabs before submitting data.

Submit Data

  I have Completed all of the above History Tabs and am Ready to Submit my Information