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 None
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

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.

Vision vs. Medical Insurance

Most people have both vision and medical insurance. They are very different in the terms of the services they cover and it’s important to understand those differences. Vision coverage is mainly designed to determine a prescription for glasses, help pay for glasses or contacts, and to screen for medical conditions. It is not designed to be used for medical conditions, diagnostic or screening tests, or treatment plans. Some medical plans have a vision benefit.

When a medical diagnosis or condition is present (such as diabetes, high blood pressure, etc.) or an eye disease (such as infections, dry eye, allergies, cataracts, etc.) it is necessary to file the claim for your visit to
your medical plan, and the co-pays, co-insurance, non-covered services, and deductibles apply. Vision
insurance does not cover medical eye problems. Our office does not make the rules; they are defined by insurance carriers and we are required to follow them.

In most cases, it is difficult to know prior to examination which type of insurance will apply or with whom our office will be able to file a claim for you. We make every effort to determine as much information for you in advance.

I understand the paragraphs above and authorize Corridor Family Eyecare to file a claim on my behalf and I understand that I am responsible for any co-pays, co-insurance, or deductible not yet met.
Patient Signature *

Clear
Patient Name *

First Name Last Name
Date *

Month Day Year
Corridor Family Eyecare Robert T. Kingus O.D.
5350 Kirkwood Blvd. SW Suite 100, Cedar Rapids, IA 52404 Tel: 319-365-2946 Fax:319-365-2948
www.corridorfamilyeyecare.com corridorfamilyeyecare@gmail.com
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