Patient Intake Form

Welcome to Our Office!
Please Complete the Following Information.

Patient Information

Last Name

First Name

Middle

Date of Birth

Age

Home Address

Apartment #/P.O. Box

City

State

ZIP

Social Security Number LAST 4 DIGITS

Marital Status

Single Widowed Married Divorced

Gender

Male Female

Race

Home / Office Telephone

Mobile Telephone

Email Address

Occupation /Grade

If Patient is Under 18 Years or a Student

Name of Parent / Guardian

Work Telephone

Mobile Telephone

Medical Information

Name of Primary Care Physician

Date of Last Physical Exam

Name / Place of Previous Eye Dr.

Date of Last Eye Exam

Vision Insurance Coverage

Name of Insurance Company - Vision Coverage

Name of Policy Holder Member

Member Date of Birth

Medical Insurance Company

Name or Medical Insurance Company

Policy Holder Name (Employer)

Policy Holder Social Security #

Relationship to Patient

Group Name

Group #

ID #

About Your Eye Examination

Several procedures are required to examine the health of your eyes and to determine treatment and/or the prescription for your eyewear. The comprehensive examination generally requires the instillation of eye drops to dilate the pupil of the eye. Dilating drops allow the doctor to examine the structures inside of the eye. These drops may result in light sensitivity, hazy vision, and difficulty focusing at near, for a duration of four (4) to eight (8) hours. Please exercise caution while driving, operating equipment, or reading during the duration of these effects.

I acknowledge the importance of dilating drops and understand the effects on my vision.

the use of DILATING DROPS.

I have read and understood the information on the OPTOMAP (Add $39.00) OR the OPTOMAP / OCT COMBINATION (Add $45.00).

Patient or Legally Authorized Individual Signature

Date

Reason for Visit

Annual Examination

Eye Health Evaluation

Pre or Post Operative Care

Emergency, Injury, Trauma

Contact Lens Fitting

LASIK Consultation

Diabetic Eye Exam

Glaucoma Evaluation

Other

If other, please specify

Do You Currently

Wear Glasses?

Yes No

How long?

Wear Contact Lenses?

Yes No

Brand

Years worn?

Do you work on a computer?

Yes No

# Hours per day?

Are You Interested In?

Contact Lenses?

Yes No

Type?

Changing your eye color?

Yes No

Please specify

Seeing without glasses?

Yes No

Please specify

Do you work on a computer?

Yes No

Please specify

Have You Had?

Cataract Surgery?

Yes No

Please Describe

Eye Muscle Surgery?

Yes No

Please Describe

Retinal Surgery?

Yes No

Please Describe

Refractive Surgery (LASIK)?

Yes No

Please Describe

LASIK Consultation?

Yes No

Please Describe

Eye Injury? Trauma?

Yes No

Please Describe

Foreign Body?

Yes No

Please Describe

Corneal Scars?

Yes No

Please Describe

If other, please specify

Social History?

Do you smoke?

Yes No

Pack(s)/Day

Do you drink alcohol?

Yes No

Pack(s)/Day

Females?

Are you Pregnant/Nursing?

Yes No

Other Disorders / Diseases?

Please Describe

Medication

Please LIST ALL Medications and Conditions treated (include Vitamins, Recreational and Over the Counter Drugs)

None Other

Please LIST ALL

Conditions being treated

None Other

Please list or describe

Health History: Do you or any blood relatives have any health conditions? (Mother, Father, Sibling-sister/brother, Grandparent)

No Known Health Condition for Myself or My Relatives.

Otherwise:

Cardiovascular, Heart Disease

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Cholesterol

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

High Blood Pressure, Stroke

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Diabetes —Type 1or Type 2

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Ears, Nose, Sinusitis, Throat

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Cough / Cold / Infection

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Hearing Impairment

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Endocrine, Hormonal Disorder

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Thyroid Disorder

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Genital, Kidney Disease, Bladder, Urinary

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Menopause, Endometriosis

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Sexually Transmitted Disease

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Hematologic / Blood Disorder / Lymphatic

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Anemia, Sickle Cell

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Immunologic, HIV Positive (AIDS)

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Collagen Vascular, Lupus

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Muscles, Bones, Joints, Arthritis

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Fibromyalgia

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Multiple Sclerosis

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Neurological, Headaches, Migraines

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Dizziness / Vertigo

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Multiple Sclerosis

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Seizures

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Psychiatric, Anxiety, Depression

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Insomnia

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Respiratory, Breathing

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Asthma, Bronchitis, Emphysema

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Skin, Integumentary, Acne, Rosacea

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Basal Cell, Skin Cancer

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Eczema, Psoriasis, Dermatitis

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Herpes Simplex, Zoster, Shingles

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Stomach, Gastrointestinal Disease

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Hepatitis

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

General Constitution

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Fatigue, Weakness, Numbness

Yes No

Who?

You

Mother

Father

Sibling

Grandparent

Allergies

List all Medications, Food, Tape, Latex, Dyes, etc.

None

Environmental

Seasonal

Other

If other, please specify

Your information will be encrypted.

Patient Intake Form

Welcome to Our Office!Please Complete the Following Information.

Patient Information

If Patient is Under 18 Years or a Student

Medical Information

Vision Insurance Coverage

Medical Insurance Company

About Your Eye Examination

Medication

Health History: Do you or any blood relatives have any health conditions? (Mother, Father, Sibling-sister/brother, Grandparent)

Allergies

Lifetime Eyecare Organization

Welcome to Our Office!
Please Complete the Following Information.