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

I don't know
Please enter the name of who performed the last eye exam

I don't know
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	No
Eczema
Other

Vascular/Cardiovascular *

	Yes	No
High Blood Pressure
Vascular Disease

Constitutional *

	Yes	No
Cancer
Weight Loss / Gain

Gastrointestinal *

	Yes	N
Diarrhea
Constipation
Crohn's / IBD

Neurological *

	Yes	No
Headaches
Migraines
Seizures

Respiratory *

	Yes	No
Asthma
Chronic Bronchitis
Emphysema

Eyes *

	Yes	No
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	No
Allergies/ Hay Fever
SInus Congestion
Runny Nose
Post-Nasal Drip
Chronic Cough
Dry Throat/Mouth

Bones/Joints/Muscles *

	Yes	No
Arthritis
Muscle Pain
Joint Pain

Psychiatric *

	Yes	No
Depression
Anxiety
ADD
ADHD

Genitourinary *

Yes No

Lymphatic/Hematologic *

	Yes	No
Anemia
High Cholesterol

Endocrine *

	Yes	No
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	No	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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