ONLINE WELCOME FORM

 

You have been directed to eyeQ's Welcome Form. Please take a few minutes to complete this form before your first visit to our office. When you've complete the Patient Welcome Form please click "Submit" and it will be emailed directly to our office. The more information you provide, the more efficient and thorough your exam will be. We look forward to meeting you soon!

(This form is hosted on a secure server by optometry.net)

 

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

     

 

 

 

Race

American Indian or Alaska Native

Asian

Caucasian

 

Black or African American

White

Not Disclosed

 

Native American

Refuse to Specify

 

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 Vision Insurance Information

Insurance Company

     

Insured's First Name

     

Insured's MI

     

Insured's Last Name

     

Date of Birth (MM/DD/YYYY)

     

 

Insured's ID

     

Group Number

     

Patients relationship to insured?

Self

Spouse

Child

Other

 

 

Complete Your Health Insurance Information

Insurance Company

     

 

Insured's First Name

     

Insured's MI

     

Insured's Last name

     

 

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

     

 

 

 

Complete Your Health History

Main Reason for today's visit?

     

 

Last Exam Date? (MM/DD/YYYY)

     

 

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 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

How many hours of computer use per day?

     

Distance from Computer?

     

 

Complete Your 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

 

 

Complete Your Social History

Current occupation

     

Years?

     

Employer Name

     

Do you drink alcohol? If yes - how often?

No

Occasional

1 per day

 

2-3/day

4+/day

 

 

 

 

Smoking Status

Current every day smoker

 

 

Current some day smoker

 

 

Former smoker

 

 

Never smoker

 

 

Smoker, current status unknown

 

Unknown if ever smoked

 

 

 

 

 

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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