Welcome to Eyes on High / Patient Questionnaire

Welcome to Eyes on High

Please take the time to fill out this registration card completely, this will ensure you receive the professional care and service that you deserve.
Reason for visit:
How did you hear about us?
Personal Information HIPPA compliant submission
Name

First Name Last Name
Birthdate

Month Day Year
Date
Social Security Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone Number

Area Code Phone Number
Secondary Phone Number

Area Code Phone Number
Email
example@example.com
Occupation
Hobbies
Parent / Legal Guardian
Vision Care Benefit / Medical Insurance Information
Primary VISION plan (VSP, EYEMED, OSU Vision Plan, Etc)
Policy Holder Name if not the patient
Policy Holder Date of Birth if not the patient

Month Day Year
Date
Secondary Vision Plan Name if Applicable
Below you can help us by including your MEDICAL ID card images, so we don't have to scan them in office (helping avoid unnecessary contact/contamination). Even if you plan to use your Vision Care Benefit (VSP or EYEMED), it helps us to coordinate your benefits better with knowledge of your MEDICAL (Anthem, Aetna, Cigna, Medicare, Medicaid) insurance carrier.

Note: You do NOT need to upload your Vision Care Benefit IDs (Eyemed/VSP)
Primary MEDICAL Insurance (Anthem, OSU Health, Cigna, Aetna, Medicare, Medicaid)
Policy Holder Name if not the patient
Policy Holder Date of Birth (If not the patient)

Month Day Year
Date
Medical ID# (not needed if you submit ID card image)
Policy Holder Social Security Number
Upload FRONT of PRIMARY MEDICAL ID card (we do not need VSP or Eyemed card info)

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Cancel of
Upload BACK of PRIMARY MEDICAL ID Card (we do not need VSP or Eyemed card info)

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Cancel of
Secondary MEDICAL insurance if applicable
Upload FRONT of SECONDARY MEDICAL ID card (we do not need VSP or Eyemed card info

Browse Files

Cancel of
Upload BACK of SECONDARY MEDICAL ID card (we do not need VSP or Eyemed card info

Browse Files

Cancel of
Patient Eye Health History
Do you wear glasses? Check all that apply:

I do not currently wear glasses I wear glasses full time I wear them part time (for driving or reading) I am looking to replace my current eyeglasses
Age of current glasses
If you use a computer at home or at your workplace frequently, select all that apply:

I wear glasses to clearly see my computer I need improvement in my ability to see the computer I have no issue with seeing the computer with my current correction I am interested in a new pair of glasses for help with my workstation/computer
Do you wear contact lenses, check all that apply:

I do not wear contact lenses I wear contact lenses full time I occasionally wear contact lenses I am interested in learning whether contact lenses would be an option for me
Brand of contact lenses and frequency of replacement (if you are new patient, bring your current box of contact lenses to your appointment)
Please select all that apply to your PERSONAL eye history:

I have no significant eye issues listed below history of an eye injury history of eye surgery glaucoma or have been told I am a suspect for glaucoma cataracts macular degeneration retinal tear or retinal detachment amblyopia / lazy eye diabetic retinopathy
Any other eye issues not listed above
Prior Eyecare Provider if not Eyes on High
Last eye exam (if new patient)
List of current eye medications or drops used
Personal medical history
Select all conditions that you have been previously/currently treated for:

Diabetes Type 1 or Type 2 Hypertension Cholesterol Heart Disease Hypothyroid (low) Hyperthyroid (high) Stroke Cancer Headaches/Migraine Acid Reflux Arthritis Respiratory (COPD, Asthma) Seasonal Allergies
Other medical conditions not listed above:
List of current medications
Upload list of medications if applicable (photo or file)

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Medication allergies
Are you a smoker?

Yes, I am a current smoker I am a former smoker I have never smoked
If you are a current smoker, how many packs per day
Do you drink alcohol?

Current drinker Former drinker I have never drank alcohol
Estimated drinks consumed per week
Family Health History
Family history of CANCER

Mother Father Brother Sister None / Not Applicable
Family history of DIABETES

Mother Father Brother Sister None / Not Applicable
Family history of high blood pressure

Mother Father Brother Sister None / Not Applicable
Family history of HYPOTHYROID (LOW)

Mother Father Brother Sister None / Not Applicable
Family history of HYPERTHYROID (HIGH)

Mother Father Brother Sister None / Not Applicable
Family Ocular History
Family history of GLAUCOMA

Mother Father Brother Sister Other Relative None / Not Applicable
Family history of Macular Degeneration

Mother Father Brother Sister Other Relative None / Not Applicable
Family history of RETINAL DETACHMENT

Mother Father Brother Sister Other Relative None / Not Applicable
Family history of BLINDNESS for any reason

Mother Father Brother Sister Other Relative None / Not Applicable
Any other significant eye history of family members
Should be Empty:

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Welcome to Eyes on High

Personal Information HIPPA compliant submission

Vision Care Benefit / Medical Insurance Information

Patient Eye Health History

Personal medical history

Family Health History

Family Ocular History