Northwest Eye Care

Demographic Information
Name*
First Last
Today's Date
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
MM slash DD slash YYYY
Home Phone
Work Phone
Cell Phone*
Email*
Employer
Occupation
Marital Status*
Name of Parent or Spouse
First Last
Spouse Date of Birth
MM slash DD slash YYYY
Name of Last Eye Doctor*
First Last
Date Of Last Eye Exam
MM slash DD slash YYYY
The following demographic questions in regards to race, ethnicity, and preferred language are voluntary.
Race:
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or Other Pacific Islander
- Caucasian
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?
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*
MM slash DD slash YYYY
Vision Insurance*
Member Number*

Northwest Eye Care

Demographic Information

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

Personal and Family Medical History

Current Corrective Lenses

Social History

Review of Systems

Constituional

Integumentary

Neurological

Eyes

Endocrine

Ear, Nose, Mouth, Throat

Respiratory

Vascular/Cardiovascular

Gastrointestinal

Genitourinary

Muscoloskeletal

Hematologic/Lymphatic

Insurance Information