corridorfamilyeyecare.com-NEW PATIENT INFORMATION

NEW PATIENT INFORMATION
Patient Name

First Name Last Name
Middle Initial
Cell Phone
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Birth Date

Month Day Year
Gender

Male Female
Race/Ethnicity
Language Preference
Email
example@example.com
Do you prefer to be reminded that you are due for your next eye exam by:

Mail Phone
Check the box which apply:

Single Married Widowed Employed Part-Time Student Full-Time Student
Employer:
School Name
EMERGENCY CONTACT INFORMATION
Emergency Contact:

First Name Last Name
Relationship to patient
Home Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
RESPONSIBLE PARTY (INSURANCE)
Name

First Name Last Name
Birth Date

Month Day Year
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
VISUAL AND MEDICAL HISTORY
Date of last eye exam:

Month Day Year
By Whom?
Do you presently wear:

Eyeglasses Contacts Both Neither
How old are your glasses?
Brand of contact lenses?
Are your contacts comfortable?

Yes No
How old are your contacts?
Name of Medical doctor:
Phone Number

Area Code Phone Number
List all of your current medications with dosage and usage (include oral contraceptives, aspirin, otc and or herbal meds.)
Do you have allergies to any medications?

Yes No
If yes please list & specify reaction:
List all surgeries and/or hospitalizations you have had:
Check any of the following you have had:

Crossed Eyes Retinal Disease Eye Pain Floaters Lazy Eye Cataracts Itching Flashes Drooping Eyelid Eye Infections Tearing Halos around lights Prominent Eyes Eye Injury Burning Glaucoma Double Vision Redness
Please list your height:
Weight:
Are you pregnant or nursing?

Yes No
Are you:

Right Handed Left Handed
FAMILY MEDICAL HISTORY

Please select relationship to any medical history or none for every option.

DISEASE/CONDITION

None

Mother

Father

Sister

Brother

Blindness

Cataract

Glaucoma

Lazy Eye

Macular Degeneration

Retinal Detachment

Retinal Disease

Arthritis

Cancer

Diabetes Type 1 / 2

Heart Disease

High Blood Pressure

Kidney Disease

Lupus

Thyroid Disease- Hyper - Hypo

REVIEW OF SYSTEMS

Do you currently, or have you ever had any issues in the following areas: (Check the box if your answer is yes )

Integumentary (Skin)

Yes

Eczema

Other

Vascular/Cardiovascular

Yes

High Blood Pressure

Vascular Disease

Constitutional

Yes

Cancer

Weight Loss / Gain

Gastrointestinal

Yes

Diarrhea

Constipation

Crohn's / IBD

Neurological

Yes

Headaches

Migraines

Seizures

Respiratory

Yes

Asthma

Chronic Bronchitis

Emphysema

Eyes

Yes

Loss of Vision

Blurred Vision

Distorted Vision/Halos

Loss of Side VIsion

Dryness

Mucous Discharge

Sandy or Gritty Feeling

Foreign Body Sens.

Light Sensitivity

Chronic Eye / Lid Infection

Styes or Chalazia

Flashes/Floater

Tired Eyes

Itching

Excess Tearing/Watering

Allergic/Immunologic (Ear, Nose, Mouth, Throat)

Yes

Allergies/ Hay Fever

SInus Congestion

Runny Nose

Post-Nasal Drip

Chronic Cough

Dry Throat/Mouth

Bones/Joints/Muscles

Yes

Arthritis

Muscle Pain

Joint Pain

Psychiatric

Yes

Depression

Anxiety

ADD

ADHD

Genitourinary

Yes No

Lymphatic/Hematologic

Yes

Anemia

High Cholesterol

Endocrine

Yes

Thyroid/Other Glands

Diabetes

If you answered Yes to any of the above or have a condition not listed, please explain:
If you answered question (?) to any of the above, please explain:
SOCIAL HISTORY

(This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.)

____ Yes, I prefer to discuss my Social History with the doctor.

Yes

If yes, type/amount/how long

Do you drink alcohol ?

Do you use other tobacco products?

Do you vape?

Do you use illegal drugs?

Are you a smoker:

Current Everyday Current Some Days Former Smoker Never Smoked
I, the patient/guardian/responsible party, have accurately and truthfully completed the information listed on this form. I agree that all fees incurred are my responsibility regardless of insurance coverage. I acknowledge that I have received a “Notice of Privacy Practices” regarding the use and disclosure of my health information. (Form is available at the front desk.)
Patient/Guardian Signature

Clear
Date

Month Day Year

ACKNOWLEDGEMENT
OF
NOTICE OF PRIVACY PRACTICES
I was given and have read Corridor Family Eyecare Notice of Privacy Practice and agree to continue my care with Corridor Family Eyecare under said terms.
Patient Signature

Clear
Date

Month Day Year
If you are signing as a personal representative of the patient, please indicate your relationship.
Representative Signature

Clear
Relationship to Patient
I give permission to Corridor Family Eyecare to discuss my health care needs with if I am unable to speak with them personally.