POULSBO EYECARE CENTER

Online Patient Form

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Demographics


Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Birth Sex Pronouns
Marital StatusEmployment Status
Misc/GuardianEmployer / School Name



Vision Plan 1

Insurance Information

Metlife, Ameritas, and DeltaVision members please select "Vision Service Plan" as your Insurance Name.

If you do not see your insurance listed, we may not be able to bill for your visit. Please contact the billing office at 360-779-2336, Option 3, for more information.

Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Vision Plan 2

Insurance Information

Metlife, Ameritas, and DeltaVision members please select "Vision Service Plan" as your Insurance Name.

Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical Plan 1

Insurance Information

If you do not see your insurance listed, we may not be able to bill for your visit. Please contact the billing office at 360-779-2336, Option 3, for more information.

Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical Plan 2

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:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical Plan 3

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:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

Eye / Medical History

What Is The Primary Reason For Visit?


Last Eye Exam: Doctor:


Glasses?
All the timeDrivingOccasionallyWatching televisionReadingComputer
Contacts?


Symptoms Checklist

Eye Medications


EYES
Dryness
Itching
Burning
Watery/Tearing
Discharge/Crusting
Redness
Pain
Strain/Pulling
Eyelid droop
Sandy/Gritty Feeling
Eyelid twitching
VISION
Double vision
Blurred Vision-Distance
Poor night vision
Light Sensitive
Floaters
Flashing lights
Blurred Vision-Near
Glare/Halos






Current And Past Eye History / Surgical Checklist

Cataracts
     Cataract Surgery
Glaucoma
     Glaucoma Surgery
Macular Degeneration
     Injections for Macular Degeneration
Retinal Disease or Detachments
     Retinal Surgery
Corneal Disease
     Corneal Surgery (RK, PRK, LASIK)
Eye Infections
Eye Injury/Trauma
Temporary Vision Loss
Crossed/Lazy Eye
     Strabismus/Eye Muscle Surgery


Family Ocular History

Macular Degen:
Glaucoma:
Cataracts:
Retinal Detach:
Crossed / Lazy:
Corneal Disease
Other:


Personal Medical History / Family Medical History / Social History

Answer: Yes or No or Previously

Allergies
High Blood Pressure
Heart Disease
Asthma/Lung Disease
Kidney Disease
Arthritis/Autoimmune Disease
Migraine Headaches
Thyroid Disease
Diabetes
A1C Level
High Cholesterol
Anxiety or Depression
Heart Attack
Cancer
AIDS/HIV
Stroke
Shingles
Pregnant Or Nursing:
Premature Birth


Current and Past Medical History

No Current Medications
No Known Drug Allergies

Primary Care Physician
Last Med. Exam:
Systemic Meds:
Drug Allergies
Injuries, Surgeries, Hospitalization


Family Medical History

FAMILY MEDICAL HISTORY - Unknown family history


Social History

Tobacco (Age 13+)
Occupation:
Hobbies:

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