Northwest Eye Care

Demographic Information

Name*

First Last

Today's Date

Address*

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

Date of Birth*

Home Phone

Work Phone

Cell Phone*

Email*

Employer

Occupation

Marital Status*

Name of Parent or Spouse

First Last

Spouse Date of Birth

Name of Last Eye Doctor*

First Last

Date Of Last Eye Exam

The following demographic questions in regards to race, ethnicity, and preferred language are voluntary.

Race:

Ethnicity: Are you Hispanic/Latino?

Yes
No

What is your preferred language?

How did you find out about our office?*

If other, tell us here:

Personal and Family Medical History

Family History includes your parents, grandparents, siblings, and your children.

Allergies

None
Self
Family

Which Family Member(s)?

Asthma

None
Self
Family

Which Family Member(s)?

Arthritis

None
Self
Family

Which Family Member(s)?

Cancer

None
Self
Family

Which Family Member(s)?

Heart Disease

None
Self
Family

Which Family Member(s)?

High Cholesterol

None
Self
Family

Which Family Member(s)?

High Blood Pressure

None
Self
Family

Which Family Member(s)?

Headaches

None
Self
Family

Which Family Member(s)?

Skin Disorder

None
Self
Family

Which Family Member(s)?

Kidney Problems

None
Self
Family

Which Family Member(s)?

Thyroid Disease

None
Self
Family

Which Family Member(s)?

Anxiety

None
Self
Family

Which Family Member(s)?

Cataracts

None
Self
Family

Which Family Member(s)?

Glaucoma

None
Self
Family

Which Family Member(s)?

Macular Degeneration

None
Self
Family

Which Family Member(s)?

Eye Injury

None
Self
Family

Which Family Member(s)?

Eye Surgery

None
Self
Family

Which Family Member(s)?

Blindness

None
Self
Family

Which Family Member(s)?

Diabetes

None
Self
Family

Which Family Member(s)?

Retinal Detachment

None
Self
Family

Which Family Member(s)?

Retinal Disease

None
Self
Family

Which Family Member(s)?

Lazy Eye

None
Self
Family

Which Family Member(s)?

Crossed Eyes

None
Self
Family

Which Family Member(s)?

Depression

None
Self
Family

Which Family Member(s)?

List any medications and dosages:

Including oral contraceptives, aspirin, over-the-counter medications and home remedies.

Are you allergic to any medications?

Yes
No

Please list the medications you are allergic to.

Are you pregnant and/or nursing?*

Yes
No

Are you under the care of a physician?

Yes
No

Please name your physician.

Current Corrective Lenses

Do You Wear Eyeglasses?*

Yes
No

How old are your present pair of lenses?

Do you wear contact lenses?*

Yes
No

If you wear contact lenses, which type?

Rigid Gas Permeable
Soft disposable
Extended wear
Colors

How often do you replace your contact lenses?

What brand do you wear?

Are you satisfied with your present contact lenses?

Yes
No

Why or why not?

Social History

This information is kept strictly confidential.

Do you drive?

Yes
No

Do you have visual difficulty when driving?

Yes
No

Please describe the visual difficulty you experience when driving.

Do you use tobacco products?

Yes
No

What type of tobacco products do you use, and how long have you been using them?

Please select which smoking status applies to you:

Current Everyday Smoker
Current Some Day Smoker
Former Smoker
Never Been a Smoker

Do you drink alcohol?

Yes
No

What type of alcohol do you drink, what amount, and how long have you been drinking it?

Do you use illegal drugs?

Yes
No

If you use illegal drugs, what type, what amount, and how long have you used them?

Have you ever been exposed to or infected with:

Gonorrhea
Hepatitis
HIV
Syphilis
None of these

Review of Systems

Do you currently, or have you ever had, any problems in the following areas:

Constituional

Fever, Weight Loss/Gain

Yes
No
?

Integumentary

Skin

Yes
No
?

Neurological

Headaches

Yes
No
?

Migraines

Yes
No
?

Seizures

Yes
No
?

Eyes

Loss of Vision

Yes
No
?

Blurred Vision

Yes
No
?

Distorted Vision/Halo

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/Watering

Yes
No
?

Glare/Light Sensitivity

Yes
No
?

Eye Pain or Soreness

Yes
No
?

Chronic Infection of the Eye or lid

Yes
No
?

Sties or Chalazion

Yes
No
?

Flashes/Floaters in Vision

Yes
No
?

Tired Eyes

Yes
No
?

Endocrine

Thyroid/Other Glands

Yes
No
?

Ear, Nose, Mouth, Throat

Allergies/Hay Fever

Yes
No
?

Sinus

Yes
No
?

Runny Nose

Yes
No
?

Post-Nasal Drip

Yes
No
?

Chronic Cough

Yes
No
?

Dry Throat/Mouth

Yes
No
?

Respiratory

Asthma

Yes
No
?

Chronic Bronchitis

Yes
No
?

Emphysema

Yes
No
?

Vascular/Cardiovascular

Diabetes

Yes
No
?

Heart Pain

Yes
No
?

High Blood Pressure

Yes
No
?

Vascular Disease

Yes
No
?

Gastrointestinal

Chronic Diarrhea

Yes
No
?

Chronic Constipation

Yes
No
?

Genitourinary

Genitals/Kidneys/Bladder

Yes
No
?

Muscoloskeletal

Rheumatoid Arthritis

Yes
No
?

Muscle Pain

Yes
No
?

Joint Pain

Yes
No
?

Hematologic/Lymphatic

Anemia

Yes
No
?

Bleeding Problems

Yes
No
?

Allergic/Immunologic

Yes
No
?

Psychiatric

Yes
No
?

If you answered yes to any of the above, or have a condition not listed, please explain and list medications:

Insurance Information

Major Medical Insurance*

Member Number*

Member Name*

First Last

Member DOB*

Vision Insurance*

Member Number*