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Greeley Eye Doctors New Patient Form- English
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2017-07-06T01:14:22+00:00
Greeley Eye Doctors New Patient Form- English
Date
*
MM slash DD slash YYYY
Name
*
First
Last
Phone
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
SS#
*
Email
*
Birth Date
*
MM slash DD slash YYYY
Medical Doctor
*
Doctor's Phone
*
Medical Insurance
*
Vision Insurance
*
Last Medical Exam
*
MM slash DD slash YYYY
Last Eye Exam
*
MM slash DD slash YYYY
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
MM slash DD slash YYYY
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):
*
None
Anxiety
Arthritis
Asthma
Cancer
COPD
Coronary Artery Disease
Diabetes
GERD
Hearing Loss
Hepatitis
High Blood Pressure
HIV / AIDS
High Cholesterol
Hyperthyroidism
Hypothyroidism
Seizures / Stroke
Heart Attack
Lupus
Other
Check any eye problems that apply to YOU (present or past):
*
None
Glaucoma
Cataracts
Retinal Detachment
Macular Degeneration
Crossed-Eye
Lazy-Eye
Drooping Eyelids
Blindness
Eye Infections
Eye Injury
Other
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
*
None
Dryness
Sandy Gritty Feeling
Burning
Itching
Redness
Tearing / Watering
Eye Pain / Soreness
Mucous Discharge
Flashes / Floaters
Halos
Loss of Vision
Loss of Side Vision
Double Vision
Blurred Vision
Glare / Light Sensitivity
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
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