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Demographics

General Information
TitleFirstLastMISuffixNickname

 

Address:


City:

State/ZipCode

Home Phone:

Work Phone:

Cell Phone:

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:

Vision

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:

Employer/School:

Primary Medical

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:

Employer/School:

Secondary Medical

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:

Employer/School:

Medical History

What is your age?

 

What is your preferred name or nickname?

 

Are you male or female?

 

What are you coming in the office for?

 

What is your occupation/ job?

 

What do you like to do in your spare time? (hobbies)

 

When was your last eye exam?

 

Are you a former patient of our office?

 

If you are a new patient of our office, how did you hear about us?

 

Have you worn contact lenses?

 

Do you want contact lenses?

 

If you do wear contact lenses, what solution are you using?

 

What vision complaints are you having?

 

What medical complaints are you having with your eyes? (ie floaters, itchy, headaches, red eyes, etc.)

 

Are you having dry or itchy eyes?

 

What medications are you taking for your health?

 

What eye drops / eye medications are you using?

 

What eye problems or diseases do you have? (ie glaucoma, eye injury, eye surgery, etc.)

 

What eye diseases does anyone in the family have? (glaucoma, macular degeneration, etc.)

 

What medical diseases or problems do you have? (ie. diabetes, high blood pressure, cancer, etc.)

 

What medical diseases does anyone in your family have? (ie. diabetes, high blood pressure, cancer, etc.)

 

Could you please tell us something about yourself?  (ie. just graduated, retired, have grandkids, likes to skydive, etc.)

 

The following questions are for insurance purposes.  If you don’t want to respond please write “pt. declined to answer”.  Thanks so much.

 

 

Preferred Language

 

Race

 

Ethnicity

 

Smoking Status (if age 13 or older)

 

Do you have High Blood Pressure?

 

Height (in feet)

 

inches

 

Weight (in lbs)

 

Is there anything else you would like to tell us

 

 

 

 

 

 

 

 

Submit Data

Are you sure all of the information you gave us is correct? If so, please click Submit Data below.

Please bring your drivers license, all your insurance cards, any glasses you wear, and any contact lens related items you use (solutions, drops, cleaners, packages or boxes with contact lens prescription) to your appointment. Kindly give 24 hrs notice if you need to reschedule your appointment.