New Patient Intake Form PATIENT INFORMATIONName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY AgeSexPhone(Required)Phone Type(Required) Home Cell Work Email(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary vision insurance (write "None" if no)ID#Primary medical insurance (write "None" if no)ID#Is Responsible Party the patient?(Required) Yes No If no complete below(Required)NamePhoneRelation to responsible partyOCULAR HISTORYList any drops prescribed or over the counter you use(Required) Add RemoveSelect all conditions that applyLazy Eye Self Family Member Cataracts Self Family Member Macular Degeneration Self Family Member Eye Infection Self Family Member Glaucoma Self Family Member Eye Injuries Self Family Member Retinal Disease Self Family Member Drooping Eyelid Self Family Member Other (indicate self or family)ConditionSelf (write "Yes" or "No)Family Member (write "Yes" or "No) Add RemoveSelect the + to add another rowList all ocular procedures you have had and whenProcedureWhen Add RemoveSelect the + to add another rowDate of last eye exam MM slash DD slash YYYY Name of practice and/or doctorDo you wear glasses?(Required) Yes No Do you wear contacts?(Required) Yes No How old is your present pair?(Required)Brand or type of contact if not soft(Required)Average daily wear time (Hours)(Required)Power R(Required)Power L(Required)Solution used(Required)MEDICAL HISTORYDate of last physical exam MM slash DD slash YYYY Name of practice and/or doctorList all allergies to medications or substances as well as reactionsMedications or SubstancesReactions Add RemoveSelect the + to add another rowList all over the counter medications, prescribed medications, and/or supplements you use Add RemoveSelect the + to add another rowList all major injuries, surgeries and/or hospitalizations you have had Add RemoveSelect the + to add another rowAre you Pregnant Nursing Select all conditions that applyHypertension Self Family Member Respiratory Disease Self Family Member Rheumatoid Arthritis Self Family Member Diabetes I Self Family Member Hypercholesterolemia Self Family Member Heart Disease Self Family Member Thyroid Dysfunction Self Family Member Diabetes II Self Family Member Other (indicate self or family)ConditionSelf Self (write "Yes" or "No)Family Member (write "Yes" or "No) Add RemoveSelect the + to add another rowLast known A1C & date(Required)Last measured blood sugar & date(Required)SOCIAL HISTORYDo you drive? Yes No if yes and you experience difficulty describe belowDo you use tobacco products? Yes No ListTypeAmountHow Long Add RemoveSelect the + to add another rowDo you drink alcohol? Yes No ListTypeAmountHow Long Add RemoveSelect the + to add another rowDo you use marijuana? Yes No ListTypeAmountHow Long Add RemoveSelect the + to add another rowDo you use illegal drugs? Yes No ListTypeAmountHow Long Add RemoveSelect the + to add another rowHave you ever been infected with any of the following? Gonorrhea Hepatitis HIV Syphilis No REVIEW of SYSTEMSDo you currently, or have you ever had any problems in the following areas:Fever, weight loss/gain Yes No ? Headaches Yes No ? Migraines Yes No ? Seizures Yes No ? Loss of Vision Yes No ? Blurred Vision Yes No ? Distorted Vision Yes No ? Loss of side vision Yes No ? Double vision Yes No ? Dryness Yes No ? Mucous discharge Yes No ? Redness Yes No ? Sandy or gritty feeling Yes No ? Itching Yes No ? Burning Yes No ? Foreign body sensation Yes No ? Excess tearing Yes No ? Glare/light sensitivity Yes No ? Eye pain/soreness Yes No ? Chronic infection Yes No ? Stye/chalazion Yes No ? Flashes/floaters in vision Yes No ? Tired eyes Yes No ? Thyroid/other gland Yes No ? Allergies/Hay fever Yes No ? Sinus congestion Yes No ? Runny Nose Yes No ? Post-Nasal Drip Yes No ? Chronic Cough Yes No ? Dry Throat Yes No ? Asthma Yes No ? Chronic bronchitis Yes No ? Emphysema Yes No ? Diabetes Yes No ? Heart pain Yes No ? High blood pressure Yes No ? Vascular disease Yes No ? Diarrhea Yes No ? Constipation Yes No ? Genitals/kidney/bladder Yes No ? Rheumatoid Arthritis Yes No ? Muscle pain Yes No ? Joint pain Yes No ? Lymphatic/hematologic Anemia Yes No ? Bleeding problems Yes No ? Allergic/immunologic Yes No ? Psychiatric Yes No ? This field is hidden when viewing the formPsychiatric Yes No ? Other Add RemoveSelect the + to add another rowI understand that if my insurance cannot provide prior guarantee of payment, I will be responsible for all charges incurred at the time of service. I hereby authorize For Your Eyes Only Optometry Center to release information applicable to benefits payable for services.(Required) Yes Date(Required) MM slash DD slash YYYY Patient or Guardian SignaturePatient or Guardian SignatureCAPTCHA Δ
