New Patient Form

Please fill out this form as completely as possible and click submit after completing the Medical History part of the form. Please follow any additional instructions provided on each tab.

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
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:

Medical History

How did you find us?
Are any of your family already patients at SeePort Optometry? If so please list.
What is your Occupation:
On average, how many hours per day are you using a computer?
When was your last eye exam:
Are you interested in Safety Sunwear?
Are you interested in Computer Progressive Eyeglasses?
Are you interested in LASIK? YES
Who is your Primary Care Physician?
Have you had glare/halos affect your vision?
Do your eyes get sandy, scratchy, gritty or dry?
Are you interested in Contact Lenses?
Have you ever had Contacts? If so, what kind?
Have you experienced any Flashes of Light in your vision recently?
Do you have back up glasses for your contacts?
Do you have a current pair of Sunglasses?
Are you Diabetic?
If yes, for how long?
Are you Pregnant Or Nursing?
Please list all Medical/Drug Allergies you have had:
Please list all Medicines/Vitamins that you currently take:
Regarding your eyes, do you have/had any injuries, infections, surgeries, diseases, lazy eye or other eye problem?
Are you using any eyedrops? If so please list.
Please list all major Injuries, Surgeries, Hospitalizations you have had:
Does Anyone In Your Family Have/Had Glaucoma, Retinal Detachment, Macula degeneration, Crossed/Lazy eyes, Blindness, Cataracts, Other eye diseases
Does anyone in your family have/had Diabetes, High Blood Pressure, Heart Disease, Cancer, Athritis, Lupus, Kidney Disease, Thyroid, Other
Do you use tobacco products?
If yes, type/amount/how long?
Do you drink alcohol?
If yes, type/amount/how long?
Do you use recreational drugs?
If yes, type/amount/how long?
Have you ever been exposed to or infected with HIV, Hepatitis, Gonorrhea, Syphilis, Herpes? If so please list.
Our Doctor routinely performs dialated eye exams to allow evaluation of the internal health of your eyes. Doing this may cause blurred vision and sensitivity to light for several hours.

Do you currently have any of these problems?
GENERAL: Fever, weight loss, weight gain, fatigue?
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination
MUSCLES, BONES, JOINTS: Athritis, Joint Pains, Head or Neck Injury
SKIN: growths, rashes, acne, Rosacea
NEUROLOGICAL: Headaches, migraines, seizures
PSYCHIATRIC: Depression, Anxiety, Insomnia
ENDORCRINE: Thyroid, Diabetes
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
OTHER: Sneezing, Swelling, Redness, Itching, Hives, Lupus, Seasonal Allergies
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux
Any other relevant information?

SUBMIT


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