Intake

1
Are you a new or returning patient?Please select one. If it has been more that 3 years since your last appointment, please select NEW PATIENT
New Patient
Returning patient
2
Patient Name* This field is required.Please provide us with your name.
First Name
Middle Name
Last Name
Suffix
3
Home Address* This field is required.Please provide your current residence
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Email* This field is required.Please provide us with a current email address. (We may contact you regarding appointments and office information.)
example@example.com
5
Cell Phone NumberPlease enter the number which you prefer to be contacted by. Mobile number is preferred. (We may text you with appointment reminders and order status)
Area Code
Phone Number
6
Daytime Phone NumberIs there another number where you can be contacted?
Area Code
Phone Number
7
Social Security NumberWe use this for checking insurance benefits
###-##-####
8
Patient's Date of Birth* This field is required.
9
Emergency Contact/ Guardian* This field is required.
First Name
Last Name
10
Emergency contact number* This field is required.Please provide a number for us to call in case of an emergency.
Area Code
Phone Number
11
Relation to patient* This field is required.Emergency contact relationship to the patient
Ex. Mother, father, grandmother, etc.
12
Are you currently working?Please select all that apply to help us to customize your care.
Yes
Student
Unemployed
13
Current Occupation
Occupation
14
Work phone number
Area Code
Phone Number
15
How did you first hear about us?Let us know how you found us.
Internet Search
Maps Search
Doctor's Referral
Patient Referral
School District
YouTube
Facebook
Please select one
If referred, please let us know who referred you.
16
Are you the parent/guardian to this patient?* This field is required.If completing this form for a minor.
YESNO
17
If yes, Relation to Patient* This field is required.
Ex. Mother, Father
18
Do you have a primary care physician?
YESNO
19
Primary Care PhysicianPlease tell us their name or care facility
20
Last Primary Care Physician Exam
Date
Month
Day
Year
21
Do you have vision insurance?* This field is required.
YESNO
22
Which vision insurance do you have?* This field is required.
MES
VSP
MediCare
23
Is this an emergency or do you require urgent care services?* This field is required.
YESNO
24
At this time we are not accepting Medicare patients. By clicking "I AGREE" below, you agree to "private" or "cash pay" patient status and that you will NOT submit a claim to Medicare or receive any payment from Medicare for the services that were performed at Family Tree Optometric.* This field is required.Family Tree Optometric has decided to OPT-OUT of the Medicare program including all beneficiaries and services. A Medicare private contract will require signatures in office in order to receive care. You CAN NOT sign this contract if you are seeking emergency or urgent care; you may be asked to seek care elsewhere if this is determined to be the case.
I AGREE and will NOT submit a claim to medicare nor receive payment from Medicare for services performed.
25
Are you the primary person named on the insurance plan?* This field is required.
YESNO
26
If no, please name the primary member on insurance* This field is required.
First Name
Last Name
27
Primary Insured Social Security NumberFor checking insurance coverage
123-45-6789
28
Primary named Date of BirthFor checking insurance benefits
ex. mmddyyyy
29
Would you be interested in learning about a membership plan for exclusive savings on your visit and materials?
YESNO
30
Are you currently experiencing any of the following?Please select all that apply.
Blurred vision
Burning
Cataracts
Discharge
Distorted vision/ Halos
Double vision
Dryness
Eye/ Lid infection
Excess tearing
Flashes/ Floaters
Glaucoma
Itching
Light Sensitivity
Loss of Side Vision
Redness
Retinal Detachment/ Disease
Sandy/ Grittiness
Stye
Tired Eyes
31
Amblyopia/ Lazy eyePlease select all that apply
None/ Unknown
None/ Unknown
Sibling
Mother
Father
Grandparent
32
BlindnessPlease select all that apply
None/ Unknown
None/ Unknown
Sibling
Mother
Father
Grandparent
33
CataractsPlease select all that apply
None/ Unknown
None/ Unknown
Sibling
Mother
Father
Grandparent
34
Corneal TransplantPlease select all that apply
None/ Unknown
None/ Unknown
Sibling
Mother
Father
Grandparent
35
GlaucomaPlease select all that apply
None/ Unknown
None/ Unknown
Sibling
Mother
Father
Grandparent
36
Macular DegenerationPlease select all that apply
None/ Unknown
None/ Unknown
Sibling
Mother
Father
Grandparent
37
Retinal DetachmentPlease select all that apply
None/ Unknown
None/ Unknown
Sibling
Mother
Father
Grandparent
38
Strabismus/ Eye TurnPlease select all that apply
None/ Unknown
None/ Unknown
Sibling
Mother
Father
Grandparent
39
ArthritisPlease select all that apply
None/ Unknown
None/ Unknown
Sibling
Mother
Father
Grandparent
40
CancerPlease select all that apply
None/ Unknown
None/ Unknown
Sibling
Mother
Father
Grandparent
41
DiabetesIf yes, please provide additional information
None
None/Unknown
Sibling
Mother
Father
Grandparent
A1C%
Blood Sugar
42
Heart DiseasePlease select all that apply
None/ Unknown
None/ Unknown
Sibling
Mother
Father
Grandparent
43
High CholesterolPlease select all that apply
None/ Unknown
None/ Unknown
Sibling
Mother
Father
Grandparent
44
High Blood PressurePlease select all that apply
None/ Unknown
None/ Unknown
Sibling
Mother
Father
Grandparent
45
SeizuresPlease select all that apply
None/ Unknown
None/ Unknown
Sibling
Mother
Father
Grandparent
46
StrokePlease select all that apply
None/ Unknown
None/ Unknown
Sibling
Mother
Father
Grandparent
47
ThyroidPlease select all that apply
None/ Unknown
None/ Unknown
Sibling
Mother
Father
Grandparent
48
Please describe any other family history not listed.
Huge
Large
Normal
Small
Ok
Ok
49
Have you had any eye or other medical surgeries?
YESNO
50
Please describe any eye or medical surgeries you have had, include when it was performed.
Huge
Large
Normal
Small
Ok
Ok
51
Do you have any allergies?
YESNO
52
Please list all allergies.
Huge
Large
Normal
Small
Ok
Ok
53
Are you currently on any medications?
YESNO
54
Please list any medications you are currently taking.
Huge
Large
Normal
Small
Ok
Ok
55
Please select all that may apply* This information is strictly confidential, if you prefer, you can discuss this with your doctor in private.
Tobacco Use
Recreational Drugs
Blood Transfusion
Alcohol Consumption
Sexually Transmitted Disease Exposure
56
Personal Eye History
Last Eye Exam
Last Dilation
57
Are you currently on any eye medications or drops?
YESNO
58
Please list any medications or eye drops
Huge
Large
Normal
Small
Ok
Ok
59
Do you wear glasses?
No
Full time
Part time
60
How long have you had your current pair of glasses?
Please let us know to the the best of your knowledge.
61
What type/s of glasses do you wear?Select all that apply
Readers
Distance
Progressive
Bifocal
Computer
Safety
62
Do you wear contacts?
No
Full Time
Part time
63
What type of contact lens do you wear?
Gas Permeable (Hard Lenses)
Daily
2 Weeks
1 Month
64
How long have you been wearing your current contacts?
65
Are they comfortable?
YESNO
66
Allergies:
Yes
No
Not Sure
67
High Cholesterol:Cardiovascular
Yes
No
Not Sure
68
Heart pain:Cardiovascular
Yes
No
Not Sure
69
High blood pressure:Cardiovascular
Yes
No
Not Sure
70
Fever:Constitutional
Yes
No
Not Sure
71
Weight loss:Constitutional
Yes
No
Not Sure
72
Diabetes:Endocrine/Glands
Yes
No
Not Sure
73
Thyroid/Other Glands:Endocrine/Glands
Yes
No
Not Sure
74
Diarrhea:Gastrointestinal
Yes
No
Not Sure
75
Constipation:Gastrointestinal
Yes
No
Not Sure
76
Genitals/Kidney/Bladder:Genitourinary
Yes
No
Not Sure
77
Allergies/Hay Fever:Ear/Nose/Mouth/Throat (Head)
Yes
No
Not Sure
78
Sinus Congestion:Ear/Nose/Mouth/Throat (Head)
Yes
No
Not Sure
79
Post-nasal Drip:Ear/Nose/Mouth/Throat (Head)
Yes
No
Not Sure
80
Chronic Cough:Ear/Nose/Mouth/Throat (Head)
Yes
No
Not Sure
81
Dry Throat/Mouth:Ear/Nose/Mouth/Throat (Head)
Yes
No
Not Sure
82
Anemia:Hematologic/Lymphatic
Yes
No
Not Sure
83
Bleeding Problems:Hematologic/Lymphatic
Yes
No
Not Sure
84
Viral or Bacterial Infection:Immunologic
Yes
No
Not Sure
85
Skin Problems:Intergumentary (Skin)
Yes
No
Not Sure
86
Rheumatoid Arthritis:Bones/Joints/Muscles (Musculoskeletal)
Yes
No
Not Sure
87
Muscle Pain:Bones/Joints/Muscles (Musculoskeletal)
Yes
No
Not Sure
88
Joint Pain:Bones/Joints/Muscles (Musculoskeletal)
Yes
No
Not Sure
89
Headaches:Neurological
Yes
No
Not Sure
90
Migraines:Neurological
Yes
No
Not Sure
91
Seizures:Neurological
Yes
No
Not Sure
92
Depression/Bi-polar:Psychiatric
Yes
No
Not Sure
93
Asthma:Respiratory
Yes
No
Not Sure
94
Chronic Bronchitis:Respiratory
Yes
No
Not Sure
95
Emphysema:Respiratory
Yes
No
Not Sure
96
Weight:Patient's weight
97
Height:
98
Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as "Coronavirus", at any time or in any place. We always follow state and federal regulations and recommended personal protection and disinfection protocols to limit transmission of all diseases in our office. Despite our careful attention to disinfection, social distancing, and use of face masks, there is still a chance that you could be exposed to an illness in our office. There is no more risk than going to the grocery store, or visiting a restaurant. "Social Distancing" nationwide has reduced the transmission of the Coronavirus. Although we have taken measures to provide social distancing in our practice, due to the nature of the services we provide, it is not possible to maintain social distancing between the patient, doctor/therapist, staff and in rare cases other patients at all times. Although exposure is unlikely, by selecting "Agree" below, you are accepting the risk and consent to treatment.* This field is required.
Agree, I consent to treatmentDisagree, I would like to reschedule
99
Signature* This field is required.You agree that this information is true to the best of your knowledge
Clearby signing you attest in the positive
100
Please call the office for further assistance.* This field is required.
Office Number
101
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