New Patient Form


Thank You For Choosing EyeQ Optometry! Please fill out this brief patient history form to help us better serve you and click "Submit" on the last tab when complete!

Demographics

How Did You Hear About Us? (Select One)
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

Preferred Language:

Ethnicity:   Race: 

Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Primary

Insurance Information
Insurance Name:
Insurance Plan:
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:

Secondary

Insurance Information
Insurance Name:
Insurance Plan:
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

Insurance Information
Insurance Name:
Insurance Plan:
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


Chief Vision Issues For This Visit
PATIENT MEDICAL HISTORY
Please list any systemic history (include diabetes, hypertension, cancer, autoimmune disorders, etc.)

If diabetic what year were you diagnosed
Last a1c

Please list any Injuries, Surgeries, Hospitalization

Pregnant Or Nursing:


Primary Care Physician: Last Visit:

   Please list your current Prescription Medications (including vitamins and over-the-counter meds):
No Current Medications

Please list all drug allergies: No Known Drug Allergies

PATIENT OCULAR HISTORY
Please indicate below if you have had any of the following: Amblyopia, Dry Eyes, Eye Injuries, Eye Surgery, Flashes of Light, Floaters, Strabismus, Cataracts, Glaucoma, or Retinal Disorders

Please enter your current Eye Medications:

Last Eye Doctor: Last Eye Exam:  

Primary Vision Correction: 

Type of CLs worn in past:  Wear Time: Disposal:

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, impotence
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury
SKIN: growths, rashes, acne
NEUROLOGICAL: Headaches, migraines, seizures
PSYCHIATRIC: Depression, Anxiety, Insomnia
 ENDOCRINE: Thyroid, Diabetes
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, M.S., Lupus, HIV
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux


Smoking Status:

Alcohol:

FAMILY MEDICAL HISTORY
Please list any systemic family history (include diabetes, hypertension, cancer, autoimmune disorders, etc.)


FAMILY OCULAR HISTORY

Please list any ocular family history (including cataracts, glaucoma, macular degeneration, retinal disorders, etc)




Submit Data

After Completing All Forms Submit Data on Final Tab