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:

Vision History

Vision History
History of any eye condition(s):
Additional Notes:
I currently wear glasses:  None Part-time Full-time  What type of glasses: 

How old are the glasses?   If part-time, how often/when? 

Do you currently wear contacts? No Yes Full-time Part-time

If part-time, how often/when?  Soft Rigid Gas Permeable

What solution do you use? 

Contact Lens Brand:    What is your replacement schedule? 

Do you sleep with contacts:  Yes  No   Please list all eyedrops you use (OTC and Rx): 

How often used?:     If you don't wear contacts are you interested in a trial fitting: YesNo

Do YOU have a history of any of the following? Are you currently experiencing any of the following?                                                                        
Blindness

Headaches

Halos around lights
Eye Turn (Strabismus)

Blurred Vision

Bothered by light/sun
Lazy Eye (Amblyopia) Double Vision Frequent styes
Keratoconus Eyes "hurt" or "tired" Eyes frequently red
Macular Degeneration Floaters Eyes itch
Retinal Detachment Flashing lights Eyes burn
Glaucoma Eyes feel sandy/gritty Eyes tear
Cataracts Eyes feel dry












 



How many hours a day do you use a computer?  2-4 hrs <2 hrs  >8 hrs 4-8 hrs

Describe any visual symptoms from computer use: 

Family History


FAMILY HISTORY   Family history is unknown/adopted. 

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

Do you have a family history of (check all that apply): YES NO Relationship to you (parent,sibling,etc) YES NO Relationship to you (parent,sibling,etc)
Blindness   Cataracts  
Macular Degeneration   Glaucoma  
Retinal Detachment/Disease   Lazy Eye (Amblyopia)  
Cancer   Diabetes  
High Blood Pressure   Heart Disease  
Stroke   Thyroid Disease  
Eye Turn (Strabismus)   Poor Vision   
Other Inherited Disease   If Yes, what disease?


SOCIAL HISTORY

How often do you consume alcohol:  Smoking Status: 

Preferred Language:  Race:  Ethnicity: 

Hobbies: 

Occupation:     Who referred you to our office? 

If not referred, how did you hear about EyeScript? 

HEIGHT FT   IN 

  Weight (lbs)   Are you Left or Right Handed? 

Medical History

Physician's Name:    Last Visit Date: 

List all medications you are currently taking:    Medication Allergies/Alerts: 

no current medications                                               no known drug allergies

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? CHECK ALL THAT APPLY TO YOU:

EAR NOSE THROAT

MUSCLES, BONES, JOINTS

ENDOCRINE

IMMUNOLOGIC

Dry Mouth/Throut Head/Neck injury Thyroid Rheumatoid
Allergies/Hay fever Arthritis Diabetes Lupus
Hearing Impaired Joint Pain Other AIDS
Sinus Other Denies Other
Other Denies Denies
Denies

CARDIOVASCULAR

SKIN

BLOOD/LYMPH

GASTROINTESTINAL

High blood pressure Growths Anemia Acid Reflux
Heart Attack or Surgery Rashes Cholesterol Crohn's/Irritable Bowl
Vascular Disease Acne Bleeding Disorder Ulcer
Stroke Other Other Other
Other Denies Denies Denies
Denies

RESPIRATORY

NEUROLOGICAL

PSYCHIATRIC

GENITAL, KIDNEY, BLADDER

Asthma Alzheimers/Dementia Anxiety Kidey Stones or Disease
Bronchitis Migraines Depression Frequent Urination
Emphysema Seizures Bipolar Impotence
COPD Brain or Spinal injury Other Other
Other Other Denies Denies
Denies Denies




List any other medical conditions: 

Submit Data

After Completing All Forms Submit Data on Final Tab