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Cornell Eyecare Group
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2017-07-06T01:14:17+00:00
Cornell Eyecare Group
Patient Information
All information will be confidential.
Patient Status
*
NEW PATIENT
RETURN PATIENT
Name
*
First
Middle
Last
Birthdate
*
MM slash DD slash YYYY
Email
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Home Phone
Cell Phone
*
Business Phone
Marital Status
*
Single
Married
Divorced
Widow/Widower
What is your preferred method of communication?
Phone Call
Text
Email
Mail
Reason for today's visit
*
Reminder card/Postcard
Glasses
Contacts
Injury/Medical Exam
(NEW Patients) Whom may we thank for referring you to our office?
Other healthcare professional
Family Member
Insurance Listing
Friend
Office sign/Drive by
Office Website
Please list the name of family or friend that referred you.
Insurance Information
Social Security Number
*
Visual Insurance Company
*
ID/Policy Number
*
Group Number
*
Policy Holder Name
*
First
Last
Relationship to policy holder?
*
Employer
DO YOU HAVE ADDITIONAL INSURANCE WE SHOULD BILL?
*
Yes
No
Visual Information
Date Of Last Eye Exam
*
MM slash DD slash YYYY
Patient Eye Health
*
Amblyopia (lazy eye)
Blurred Vision-Far
Blurred Vision-Near
Burning Eyes
Cataracts
Discharge from eyes
Double Vision
Drooping Eyelid
Dry Eyes
Eye Turn
Floaters/Spots
Fluctuating Vision
Foreign Body Sensation
Glaucoma
Glare/Light Sensitivity
Headaches
Itchy Feeling
Infection of Eye/ Lid
Light Sensitivity
Loss of Vision-Central
Loss Of Vision-Side
Mucus/Discharge
Night Vision Problems
Pain in or around eyes
Redness
Retinal Detachment
Sleepy with Reading
Squinting
Strained or tired Eyes
Tearing/Watery Eyes
None of the Above
List All Current or Past Eye Diseases, Eye Injuries, or Eye Surgeries
*
Health Information
List All Medications You Are Taking
*
Medication Allergies
*
Have you had any significant changes in your health or any major health problems?
*
Yes
No
If "yes", please explain.
Patient General Health
Allergies
Asthma/Respiratory
Blood Disorders
Cancer
Hypertension
Chronic Bronchitis
Chronic Cough
Diabetes
Emphysema
Gastrointestinal Problems
Heart Attack
Stroke
Headaches/Migraines
Kidney Disorders
Psychiatric/Depression
Rheumatoid Arthritis
Thyroid Disorder
Weight Loss/Gain
None of the Above
Family History (Family History includes your parents, grandparents, siblings, and your children)
*
Blindness
Cataract
Glaucoma
Diabetes
High Blood Pressure
Cancer
Heart Disease
Thyroid Disease
Arthritis
Stroke
Macular Degeneration
None of the Above
Do You Use Tobacco Products?
*
Current
Previous
Never
Do You Drink Alcohol?
*
Socially
Daily
Never
Lifestyle Factors
Your answers will assist us in selecting the best eyewear for you!
Occupation
Do you currently participate in any hobbies or outdoor activities?
Do you use a computer?
Yes
No
Do you drive long distances?
Yes
No
Do you like to watch TV?
Yes
No
Do You Wear Eyeglasses?
*
Yes
No
Do You Wear Contact Lenses
*
Yes
No
What brand or type are your current contact lenses? (Soft, Glass Perm, and Brand)
Signature
*
Authorization - I certify that I have read, understand and answered the above information to the best of my knowledge. I consent for Cornell Eyecare to bill my insurance company.
Today's Date
*
MM slash DD slash YYYY
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