New Lenox Family Eyecare

Patient Information

Patient Information

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone:
Cell Phone: Preferred Contact Method:
Last 4 of SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Guardian

Vision Insurance

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:(if not same)
City: State: Zip:
Phone Number:
Birthday:
Last 4 of SSN:
Employer/School:

Medical Insurance

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:(if not same)
City: State: Zip:
Phone Number:
Birthday:
Last 4 of SSN:
Employer/School:

Secondary Medical Insurance

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:(if not same)
City: State: Zip:
Phone Number:
Birthday:
Last 4 of SSN:
Employer/School:

Medical History

When was your last eye exam?When was your last health exam?

Have you ever been diagnosed with:Has anyone in your family ever been diagnosed with:
Diabetes   Diabetes  
Heart Disease  Heart Disease  
Ear, Nose, Throat Disorders   Ear, Nose, Throat Disorders  
Respiratory Disorders   Respiratory Disorders  
GI, Kidney Disorders   GI, Kidney Disorders  
Muscle, Bone, Joint Disorders   Muscle, Bone, Joint Disorders  
Skin Disorders   Skin Disorders  
Neurological Disorders   Neurological Disorders  
Thyroid Disorders   Thyroid Disorders  
Immunologic, Blood, Lymph Disorders   Immunologic, Blood, Lymph Disorders  
Hypertension   Hypertension  

Do you have any of the following eye conditions:Does anyone in your family have any of the following eye conditions:
Amblyopia (Lazy Eye)   Amblyopia (Lazy Eye)  
Blindness,Vision Loss   Blindness,Vision Loss  
Cataracts   Cataracts  
Color Deficient   Color Deficient  
Glaucoma   Glaucoma  
Macular Degeneration   Macular Degeneration  
Retinal Issues   Retinal Issues  
Strabismus(Crossed Eyes)  Strabismus(Crossed Eyes) 
Eye Diseases   Eye Diseases  
Other  

Are you experiencing any of the following eye symptoms?
Foreign Body Sensation, Irritation  
Glare  
Dry Eyes  
Eye Pain  
Itching  
Double Vision
Floaters, Spots, Flashing  
Blurred Distance Vision  
Blurred Near Vision  
Discharge  
Redness  
Headaches  
Other  

Medications Eye Medications Allergies to Medications Environmental Allergies

Past Surgeries or Illnesses Primary Care Physician (name, clinic, phone number)

Social History

Do you currently wear glasses?
If so, how old are they?
How many hours a day do you use a computer?
How far away is your computer screen?
Do you wear sunglasses?
If so, are you sunglasses your prescription?

Do you currently wear contacts?
If no, are you interested in contacts?
How many hours a day do you wear your contacts?
What kind of contact lens solution do you use?
How often do you replace your contacts?

Do you use nutritional supplements?
Do you engage in regular exercise?
Do you drink alcohol?
Do you use tobacco products?
Do you use illegal drugs?

Are you pregnant or nursing?
What is your preferred language?
What is your ethnicity?
What are your hobbies and interests?

Submit Data

After Completing All Forms Submit Data on Final Tab