Complete Your Personal Information Salutation Mr. Mrs. Ms. Dr. Miss. Master Rev. First Name* Last Name* Preferred Name

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Transcription:

Please take a few minutes to complete this Patient Welcome Form before you visit our office for the first time. Print it out, fill it in, and bring the copy with you to your next appointment. Complete Your Personal Information Salutation Mr. Mrs. Ms. Dr. Miss. Master Rev. First Name* Last Name* Preferred Name Address Home Phone Email Address* MI Patient's Gender Male Female Spouse/Parent Name Account Responsibility, if different from patient Emergency Contact Name Emergency Contact Number Work Phone Phone Ext.: Date of Birth(MM/DD/YYYY)* Guardian How Found Phone Book School Ad Referred By Insurance Listing Previous Patient Drive By Other Doctor Complete Your Primary Insurance Information Insurance Company Insurance Address Insured's First Name Insured's Last Name Insureds Gender Male Female Insured's ID Insured's MI Date of Birth (MM/DD/YYYY) Group Number

Patients relationship to insured? Self Spouse Child Other Patient's Status Single Married Other Patient's Employment Status Full Time Student Part Time Student Employed Complete Your Secondary Insurance Information Insurance Company Insurance Address Insured's First Name Insured's MI Insured's Last name Insureds Gender Date of Birth (MM/DD/YYYY) Male Female Insured's ID Group Number Patient's relationship to insured? Self Spouse Child Other Complete Your Primary Care Physician First Name MI Last Name Clinic Name Address Phone Number Complete Your Referring Physician First Name MI Last Name Clinic Name Address Phone Number

Complete Your Health History Main Reason for Exam? Last Exam Date? (MM/DD/YYYY) When was your last health exam? Enter past illnesses or injuries Past Surgeries? Please list all medications or provide a list to the doctor Please list all eye drops you are currently using Please list any reactions or sensitivities you have experienced Please list any specific allergies Complete Your Eye History Glaucoma Infection of Lid Cataract Macular Degeneration Itching Mucous Discharge Retinal Detachment Drooping Eyelid Color Blindness Headaches Glare/Light Sensitivity Redness Sandy or Gritty Feeling Blurred Vision Distance Tired Eyes Blurred Vision Near Lazy Eyes Crossed Eyes

Burning Distorted Vision (halos) Dryness Excess Tearing/Watering Double Vision Floaters or Spots Eye Pain or Soreness Foreign Body Sensation Fluctuating Vision Loss of Vision Loss of Side Vision Complete Your General Health Condition Fever Muscles/Bones/Joints Weight Loss Skin Other Symptoms Neurological (i.e. Multiple Sclerosis) Ears/se/Throat Anxiety or Depression Heart conditions (i.e. high blood pressure) Thyroid/Diabetes Respiratory (i.e. Asthma) Blood/Lymph (cholesterol) Gastrointestinal Allergic Kidney Are you? Pregnant Nursing Complete Your Family History Amblyopia (Lazy Eye) Cancer Blindness Diabetes Cataract(s) Heart Disease Color Blindness High Blood Pressure Glaucoma Kidney Disease Macular Degeneration Lupus

Retinal Detachment Stroke Strabismus (i.e. Eye Turn) Thyroid Disease Arthritis Others Complete Your Spectacle Lens History Do you use a computer? How many hours/day? Distance from Computer? Do you drive? Mileage to work each way? Do you have glare problems? Do you have visual difficulty when driving? Do you have problems with night vision? Do you currently wear glasses? Since? Type of glasses? Full Time Part Time Distance Close Glasses Owned? SingleVision Bifocals Trifocals Backup Glasses Safety Sports Progressive Have you had trouble with glasses in the past? Reason: Do you wear sunglasses? Are your sunglasses your current prescription? Special eyewear needs? Computer (special prescriptions, special anti-glare tints or coatings) Occupational (mechanics, plumbers, pilots) Safety Glasses (gardening, woodworking, welding) Sports/Hobbies (racquet sports, motorcycle) Complete Your Contact Lens History Do you currently wear contact lenses? Since? If not a contact lens wearer, are you interested in trying contact lenses at this time? Have you ever tried to wear contacts? If yes, what was the reason for stopping? Type and brand of contacts?

Today's wearing time? How many hours/day? How many days/week? Please rate the following on a scale of 1-10 with 1 being POOR and 10 being EXCELLENT. Lens Comfort Right Left Distance Vision Right Left Near Vision Right Left What solutions do you use? Disinfectant used? Enzyme used? Complete Your Social History Current occupation Years? Employer Name Do you use nutritional supplements (vitamins etc.)? Do you engage in regular exercise? Do you drink alcohol? If yes - how often? Do you smoke? If yes - how much/often 2-3/day 1 pack/day Occasional 4+/day Occasional 1+ pack Method of Tobacco Intake? Smoking Chewing Do you use Illegal Drugs? List your hobbies 1 per day 1/2 pack/day Thank you for completing the Welcome Form information, we will be able to provide you with the best evaluation of your health using this information. We look forward to seeing you soon! Signature:

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