Olympia Vision Clinic

New Patient Form

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Demographics

* Indicates Required Field     ** Must Include Either Home or Cell Phone
TitleFirst* Last*MI SuffixNickname
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* (req by ins)   Employer/School Name
     Misc/Guardian
Billing Information Is The Billing Address Different? Yes
TitleFirst LastMI Suffix
Address

CityState ZipCode
Home Phone:
Work Phone:
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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?
I currently wear contacts:  Never  Full-time  Part-time     If part-time, how often/when?  
    Contact Lens Wearers:   
       Are your contact lenses comfortable?  Yes No Type of contact lenses worn:   Soft Rigid Gas Permeable
       Current Brand:  What solution do you use? 
       How often do you replace your contact lenses?   How old is your current pair? 
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?       Describe any visual symptoms from computer use:   
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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 Arthritis
     Blindness Cancer
     Eye turn (Strabismus) Diabetes
     Lazy Eye (Amblyopia) Heart Disease
     Glaucoma High Blood Pressure
     Cataracts Kidney Disease
     Macular Degeneration Stroke
     Retinal Detachment/Disease Thyroid Disease
     Color Blindness Other Inherited Disease
   
Social History (confidential)  
     Smoking Status:
     How often do you consume alcohol:
   
     Preferred Language:  Race:  Ethnicity:  
   
     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?      
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Submit Data

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