New Patient Intake Form — Visions Optique & Eyecare

01

Patient Information

First Name *

Last Name *

Date of Birth *

Parent / Guardian Name (if patient is a minor)

Mailing Address *

City *

State *

Zip Code *

Cell Phone *

Email Address *

Occupation

How did you hear about us?

Medical Insurance Co.

Vision Insurance Co.

Primary Insured Name

Primary Insured Birthdate

02

Eye History

Date of Last Eye Exam

Do you currently wear glasses?

Yes No

Do you currently wear contact lenses?

Yes No

Do you work on a computer?

Yes No

Have you ever had any of the following? Check all that apply

Have you had eye surgery for any of the following? Check all that apply

Other eye surgery

03

Medical History

Are you currently taking any medications?

Yes No

Are you pregnant or nursing?

Yes No

Please list all medications, including dosage amounts (eye drops & over-the-counter included)

Are you allergic to any medications?

Yes No

If yes, please list medication allergies

04

Family Medical & Eye History

Has anyone in your immediate family had any of the following? Check all that apply

05

Social History

Do you use tobacco products?

Yes No

Have you ever used tobacco products in the past?

Yes No

06

Review of Systems

Do you currently, or have you ever had problems in the following areas? Check all that apply — leave unchecked if no.

Vascular / Cardiovascular

Heart disease / problems High blood pressure High cholesterol Stroke

Ear, Nose, Throat, Mouth

Sinus infections Hearing loss

Respiratory

Gastrointestinal

Acid reflux Intestinal problems Liver / spleen problems

Genitourinary

Genitals / kidney / bladder

Bones / Joints / Muscles

Rheumatoid arthritis Joint pain

Skin

Rosacea Metal allergies

Neurological

Endocrine

Thyroid / other glands Diabetes

Lymphatic / Hematologic

Anemia

Psychiatric

Depression Anxiety

Immune System & Cancer

Lupus Cancer

If cancer, please specify type

Patient Health History Form

Patient Information

Eye History

Medical History

Family Medical & Eye History

Social History

Review of Systems

Eyes (Ocular Symptoms)

Vascular / Cardiovascular

Ear, Nose, Throat, Mouth

Respiratory

Gastrointestinal

Genitourinary

Bones / Joints / Muscles

Skin

Neurological

Endocrine

Lymphatic / Hematologic

Psychiatric

Immune System & Cancer