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Northwest Eye Care
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2017-07-06T01:14:30+00:00
Northwest Eye Care
Demographic Information
Name
*
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Last
Today's Date
MM slash DD slash YYYY
Address
*
Street Address
Address Line 2
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Venezuela
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Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Date of Birth
*
MM slash DD slash YYYY
Home Phone
Work Phone
Cell Phone
*
Email
*
Employer
Occupation
Marital Status
*
Single
Married
Divorced
Widow/Widower
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?
*
Friends/Family
Insurance Company
Dex Yellow Pages
Internet
Magazine/Print Ad
Other
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
*
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