Greeley Eye Doctors New Patient Form- English

Date*

Name*

First Last

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

SS#*

Email*

Birth Date*

Medical Doctor*

Doctor's Phone*

Medical Insurance*

Vision Insurance*

Last Medical Exam*

Last Eye Exam*

How did you hear about us?*

Ocular History

Do you wear glasses?*

Yes
No

If yes, how old are your current lenses?

Do you wear contact lenses?*

Yes
No

If yes, how old are your current lenses?

Type of contact lenses?

Soft
Rigid
Extended Wear
Toric
Multifocal
Monovision
Other

Do you wear them

Full Time
Part Time

Are they comfortable?

Yes
No

Have you had refractive surgery? (Lasik)*

Yes
No

If yes, Date

Type

What services would you like to be evaluated for today?*

Contact Lenses
Glasses
Refractive Surgery (Lasik)

Medical History

List any medications you are currently taking (including oral contraceptives, aspirin, over the counter medications)*

Are you allergic to any medications?*

Yes
No

If so, which ones?

Are you pregnant?*

Yes
No

List any major injuries, surgeries and/or hospitalizations you have had:*

Check any health problems that apply to YOU (present or past):*

Check any eye problems that apply to YOU (present or past):*

Family History

Please list any family members with the following conditions (parents, grandparents, siblings, children; living or deceased): Blindness, Cataract, Glaucoma, Diabetes, Macular Degeneration, Retinal Detachment, Cancer, High Blood Pressure, Heart Disease, Lupus:*

Social History (this information is strictly confidential)

Do you drive?*

Yes
No

If yes, do you have visual difficulty when driving?

Yes
No

If yes, please describe:

Do you use tobacco products?*

Yes
No

If yes, amount / how long?

Do you drink alcohol?*

Yes
No

If yes, amount / how long?

Do you use drugs?*

Yes
No

If yes, type / amount / how long?

Review of Systems and Complaints (please check all that apply to you)

Eyes*

Constitutional*

None
Fever
Weight Loss / Gain

Integumentary / Hematologic*

None
Skin Disease
Anemia
Cancer
Scalp Tenderness

Neurological*

None
Headaches
Migraines
Seizures

Ears, Nose, Throat*

None
Dry Throat / Mouth
Congestion / Runny Nose
Allergies / Hay Fever

Respiratory*

None
Chronic Cough
Bronchitis
Asthma
Emphysema

Psychiatric*

None
Anxiety
Depression

Musculoskeletal*

None
Rheumatoid Arthritis
Muscle Pain
Joint Pain

Gastrointestinal*

None
IBS / Crohn's Disease
Diarrhea
Constipation