Online Welcome Form

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 Secondary Insurance Information
Insurance Company
Insurance Address					City
State					Zip
Insured's First Name					Insured's MI
Insured's Last name
Insureds Gender	Male	Female			Date of Birth (MM/DD/YYYY)
Insured's ID					Group Number
Patient's relationship to insured?			Self	Spouse		Child	Other

Complete Your Primary Care Physician
First Name		MI
Last Name
Clinic Name
Address		City
State		Zip
Phone Number

Complete Your Referring Physician
First Name		MI
Last Name
Clinic Name
Address		City
State		Zip
Phone Number

Complete Your Health History
Main Reason for Exam?
Last Exam Date? (MM/DD/YYYY)
When was your last health exam?
Enter past illnesses or injuries
Past Surgeries?
Please list all medications or provide a list to the doctor


Please list all eye drops you are currently using


Please list any reactions or sensitivities you have experienced
Please list any specific allergies

Complete Your Contact Lens History
Do you currently wear contact lenses?	Yes No			Since?
If not a contact lens wearer, are you interested in trying contact lenses at this time?					Yes	No
Have you ever tried to wear contacts?		Yes	No
If yes, what was the reason for stopping?
Type and brand of contacts?
Today's wearing time?
How many hours/day?
How many days/week?

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
What solutions do you use?
Disinfectant used?
Enzyme used?

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!

Complete Your Personal Information
Salutation		Mr. Mrs. Ms. Dr. Miss. Master Rev.
First Name*			MI
Last Name*
Preferred Name
Address			City
State			Zip
Home Phone			Work Phone
Social Security Number			Phone Ext.:
Email Address*			Date of Birth (MM/DD/YYYY)*
Patient's Gender		Male Female
Spouse/Parent Name			Guardian
Account Responsibility, if different from patient
Emergency Contact Name
Emergency Contact Number
How Found	Phone Book		School	Ad	Previous Patient
	Insurance Listing		Drive By	Other	Doctor
Referred By

Complete Your Spectacle Lens History
Do you use a computer?		Yes	No
How many hours/day?
Distance from Computer?
Do you drive?		Yes	No
Mileage to work each way?
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	Since?
Type of glasses?		Full Time Part Time Distance Close
Glasses Owned?	SingleVision	Bifocals	Trifocals		Backup Glasses
	Safety	Sports	Progressive
Have you had trouble with glasses in the past?		Yes	No	Reason:
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)

Complete Your Social History
Current occupation	Years?
Employer Name
Do you use nutritional supplements (vitamins etc.)?	Yes	No
Do you engage in regular exercise?	Yes	No
Do you drink alcohol? If yes - how often?	No	Occasional	1 per day
	2-3/day	4+/day
Do you smoke? If yes - how much/often	No	Occasional	1/2 pack/day
	1 pack/day	1+ pack
Method of Tobacco Intake?	Smoking	Chewing
Do you use Illegal Drugs?	Yes	No
List your hobbies

Complete Your Primary Insurance Information
Insurance Company
Insurance Address				City
State				Zip
Insured's First Name				Insured's MI
Insured's Last Name
Insureds Gender	Male Female			Date of Birth (MM/DD/YYYY)
Insured's ID				Group Number
Patients relationship to insured?			Self	Spouse		Child	Other
Patient's Status		Single			Married		Other
Patient's Employment Status		Full Time Student			Part Time Student		Employed

Complete Your Eye 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

Complete Your General Health Condition
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 (i.e. Asthma)	Yes	No	Blood/Lymph (cholesterol)	Yes	No
Gastrointestinal	Yes	No	Allergic	Yes	No
Kidney	Yes	No
Are you?	Pregnant Nursing

Complete Your Family History
Amblyopia (Lazy Eye)	Yes	No	Cancer	Yes	No
Blindness	Yes	No	Diabetes	Yes	No
Cataract(s)	Yes	No	Heart Disease	Yes	No
Color Blindness	Yes	No	High Blood Pressure	Yes	No
Glaucoma	Yes	No	Kidney Disease	Yes	No
Macular Degeneration	Yes	No	Lupus	Yes	No
Retinal Detachment	Yes	No	Stroke	Yes	No
Strabismus (i.e. Eye Turn)	Yes	No	Thyroid Disease	Yes	No
Arthritis	Yes	No	Others	Yes	No

Lens Comfort

Distance Vision

Near Vision