ONLINE WELCOME FORM

 

Please take a few minutes to complete this Patient Welcome Form before you visit our office for the first time. Once you fill in the information, click on the "Submit" button to e-mail it to our office or bring a copy with you to your next appointment.

 

Complete Your Personal Information

First Name*

     

MI

     

Last Name*

     

 

Preferred Name

     

 

Address

     

City

     

State

     

Zip

     

Home Phone

     

Cell Phone

     

Email Address*

     

Date of Birth (MM/DD/YYYY)*

     

 

 

Date:      

Have you or anyone in your household tested positive for COVID-19? : Yes No

Have you or anyone in your household been exposed to COVID-19, or been around someone who has? : Yes No

 

If YES, please explain:      

Do you have any of the following: fever or chills, cough, shortness of breath, difficulty breathing, body aches, headache, new loss of taste or smell, sore throat : Yes No

Where have you traveled in the last 3 months:      

 

Thank you for requesting an appointment at Eyes on Broadway! Your health and the health of our staff is our top priority. Per the Oregon Health Authoritys guidelines, we are enacting the following policies to keep everyone safe. Once we have received your completed pre-exam questionnaire, we will contact you to schedule your appointment.

If you are in a COVID-19 high-risk health category: Older adults and people of any age who have serious underlying medical conditions, we STRONGLY URGE you to consider postponing your exam until its safer for you to come into a group environment.

 

~If you have had any Covid-19 symptoms in the last month such as fever or chills, cough, shortness of breath, difficulty breathing, body aches, headache, new loss of taste or smell or sore throat- it will be necessary to reschedule your appointment to a later date.

 

~Patients will be required to wear masks while in the office and may be checked with a forehead thermometer prior to entry. Anyone with a temperature above 100.4F will be rescheduled. We reserve the right to refuse service to anyone.

 

~Patients should wear their GLASSES to the appointment. Please also bring your contact lenses and packaging.

 

~To comply with social distancing requirements, we have installed physical barriers throughout the office and will be limiting the number of patients and staff in the office at one time. With our new limited occupancy, you may be asked to wait outside or in your car until we are ready to bring you in for your appointment.

 

~Please come alone to your appointment with as few personal items as possible. A parent of young children may continue to accompany them to their appointments.

 

~Patients must be seated with an optician while selecting frames. At this time, we are not able to allow you to browse on your own. As is customary, all frames viewed will be cleaned and sanitized after each patient.

 

~We will continue working diligently to sanitize all surfaces between each patient as appropriate and as often as possible. This includes countertops, physical barriers, medical equipment, chairs, door knobs and all frequently touched surfaces.

 

 

Please Sign Date:      

 

Current Concerns

What is the main reason for today's exam:      

Other: Please Specify:      

 

 

Eye Health History

Glaucoma

Yes

No

Infection of Lid

Yes

No

Cataract

Yes

No

Itching

Yes

No

Macular Degeneration

Yes

No

Mucous Discharge

Yes

No

Retinal Detachment

Yes

No

Drooping Eyelid

Yes

No

Color Blindness

Yes

No

Redness

Yes

No

Headaches

Yes

No

Sandy or Gritty Feeling

Yes

No

Glare/Light Sensitivity

Yes

No

Blurred Vision Distance

Yes

No

Tired Eyes

Yes

No

Blurred Vision Near

Yes

No

Lazy Eyes

Yes

No

Crossed Eyes

Yes

No

Burning

Yes

No

Distorted Vision (halos)

Yes

No

Dryness

Yes

No

Double Vision

Yes

No

Excess Tearing/Watering

Yes

No

Floaters or Spots

Yes

No

Eye Pain or Soreness

Yes

No

Fluctuating Vision

Yes

No

Foreign Body Sensation

Yes

No

Loss of Vision

Yes

No

Loss of Side Vision

Yes

No

 

 

 

 

Current Health Conditions

Fever

Yes

No

Muscles/Bones/Joints

Yes

No

Weight Loss

Yes

No

Skin

Yes

No

Other Symptoms

Yes

No

Neurological
(i.e. Multiple Sclerosis)

Yes

No

Ears/Nose/Throat

Yes

No

Anxiety or Depression

Yes

No

Heart conditions
(i.e. high blood pressure)

Yes

No

Thyroid/Diabetes

Yes

No

Respiratory

Yes

No

Blood/Lymph

Yes

No

Gastrointestinal

Yes

No

Allergic

Yes

No

Kidney

Yes

No

 

 

 

Are you?

Pregnant Nursing

 

 

Current Medications:            

Current Eye Drops:            

Medicines that cause reactions or sensitives:      

Specific Allergies:      

Spectacle Lens History

Do you use a computer?

Yes

No

Distance from Computer?

How are they working for you ?

     

     

Do you drive?

Yes

No

Do you have glare problems?

Yes

No

Do you have visual difficulty when driving?

Yes

No

Do you have problems with night vision?

Yes

No

Do you currently wear glasses?

Yes

No

 

 

Type of glasses?

Full Time Part Time Distance Close

Have you had trouble with glasses in the past?

Yes

No

 

 

Do you wear sunglasses?

Yes

No

Are your sunglasses your current prescription?

Yes

No

Special Eyewear Needs

 

Computer (special prescriptions, special anti-glare tints or coatings) Occupational (mechanics, plumbers, pilots) Safety Glasses (gardening, woodworking, welding) Sports/Hobbies (racquet sports, motorcycle)

 

Contact Lens History

Do you currently wear contact lenses?

Yes No

 

If not a contact lens wearer, are you interested in trying contact lenses at this time?

Yes

No

Brand

     

 

 

Please rate the following on a scale of 1-10 with 1 being POOR and 10 being EXCELLENT.

 

Lens Comfort

Right

     

Left

     

 

Distance Vision

Right

     

Left

     

 

Near Vision

Right

     

Left

     

 

 

Thank you for completing the Welcome Form information, we will be able to provide you with the best evaluation of your health using this information. We look forward to seeing you soon!

 

 


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