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

Salutation

Mr. Mrs. Ms. Dr. Miss. Rev.

First Name*

     

MI Initial

  

Last Name*

     

 

Preferred Name

     

 

Address

     

City

     

State (MI)

     

Zip

     

Home Phone

     

Work Phone

     

Social Security Number

(No Dashes)

     

Phone Ext.:

     

Email Address*

     

Date of Birth (MM/DD/YYYY)*

     

Patient's Gender

Male Female

Spouse/Parent Name

     

 

 

Emergency Contact Name

     

Emergency Contact Number

     

Race

American Indian or Alaska Native

Asian

White

 

Black or African American

Declined to Specify

 

Native American

 

 

Native Hawaiian or Other Pacific Islander

 

 

Other Race      

 

 

 

 

 

Height

ft

     

ft in

 

In

     

 

cm/m

     

cm m

Weight

     

lbs kg

 

 

Ethnicity

Hispanic or Latino Not Hispanic or Latino Unknown

Language Preferences

English Spanish French Italian Russian Portuguese

 

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?

     

 

Past/Current Medical Conditions and 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 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

 

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

 

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?

     

 

 

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

 

 

 

 

Smoking Status

Current every day smoker

 

 

Current some day smoker

 

 

Former smoker

 

 

Never smoker

 

 

Smoker, current status unknown

 

Unknown if ever smoked

 

 

 

 

 

Method of Tobacco Intake?

Smoking

Chewing

 

Do you use Illegal Drugs?

Yes

No

 

List your hobbies

     

 

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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