KEC Patient Intake Form

Patient Intake Form

Due to the COVID-19 pandemic, we recommend that our patients complete this form prior to their appointment to reduce the amount of time spent in our office for their own health and safety and for our staff. If you are not comfortable filling out this form online, please call our office at (808) 674-2273 and a member of our staff will do a phone work-up instead. Mahalo for your cooperation.
Patient Name*

First NameLast Name
Date Of Birth*

MonthDayYear
Are there any changes to your personal information? ex: address, phone number, email, PCP*

No changesYes *Please fill out the fields below
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Preferred Contact Number
May We Contact You Through Email?*

YesNo
Email*
example@example.come
If your Primary Care Physician has changed, please type their name here:
Are there any changes to your Insurance Information? (Ex: New insurance plan/card or New subscriber or member ID#)*

No changesYes *Please fill out the fields below
Primary Insurance
Patient's Relationship To Subscriber:

Self *Skip Subscriber Name & DOB questionSpouseChildPartner
Subscriber's Name

First NameLast Name
Subscriber's Date of Birth

MonthDayYear
Subscriber ID#
Secondary Insurance
Patient's Relationship To Subscriber:

Self *Skip Subscriber Name & DOB questionSpouseChildPartner
Subscriber's Name

First NameLast Name
Subscriber's Date of Birth

MonthDayYear
Subscriber ID#
Are you taking any NEW Medications or Supplements since your last visit with us?*

No changesYes
Please list all NEW Medications or Supplements here:
Are you using any Over-The-Counter eye drops? Ex: Artificial Tears, Visine, Clear Eyes, etc.*

NoYes
Please list all Over-The-Counter eye drops you are using here:
How often are you using these eye drops?

Once a day2 times a day3 times a day4 times a dayAs Needed
What problem(s) are you coming in for today? Check all that apply.*

Yearly Eye Exam or Diabetic Eye Exam for an eye health check and to update your glasses and/or contact lens prescription(s)CataractsGlaucomaSurgery Post-Op (for surgeries done at the Eye Surgery Center of Hawaii)Sudden Blurry Vision or Loss of VisionAllergies (Redness, Itching, Tearing, Discharge)DrynessForeign Body (something stuck in eye or sensation of something in eye)HeadachesEye PainSensitivity to LightFlashes and/or FloatersSpasmGrowthDroopy Eyelid(s)Trauma/Eye InjuryOther
Please Answer These Questions Regarding Your Vision and Eye Health
Have you been diagnosed with Diabetes?*

NoYes
Do you know what your last A1C Level was?*

NoYes
What was your last A1C Level?*
Ex: 6.0%
Do you check your Blood Sugar at home?*

NoYes
What was your Last Blood Sugar reading and when was it taken?*
Ex: 100 - this AM
Do you have blurry vision or changes to your vision?*

NoYes
Which eye is affected?*

Right EyeLeft EyeBoth Eyes
What range(s) of vision have changed? Check all that apply.*

Near/ReadingComputer/Arm's LengthDistance
Do you wear glasses?*

NoYes
What kind of lenses do you have?

Distance onlyReading onlyBifocal (with a line, corrects Distance and Reading or Computer and Reading)Progressive (no-line bifocal, corrects Distance, Computer and Reading)
How old are your glasses?*

1 year old2 years old3-5 years old
Do you wear contacts?*

NoYes
What kind of contacts do you wear?*

Soft lensesRGP (Rigid Gas Permeable)CRT (Corneal Refractive Therapy)Scleral Lenses
How often do you replace your contact lenses?*

DailyEvery 2 WeeksMonthlyQuarterly (every 3-4 months)
Are you experiencing any dryness while wearing your contacts?*

NoYes
Do you have a history of dry eyes or recently experienced any dryness?*

NoYes
Are you using Gentle Cleanser or a similar product to cleanse your eyelids?*

NoYes
How often are you using it?*

Once a day2 times a dayOnce a week2 to 3 times a weekOccasionally
Are you using using a Warm Compress?*

NoYes
How often are you using it?*

Once a day2 times a dayOnce a week2 to 3 times a weekOccasionally
Are you taking Omega-3 Fish Oil Vitamins?*

NoYes
Are you in air conditioning often?*

NoYes

Please Answer These Questions Regarding Cataracts
Has your vision changed?*

NoYes
What range(s) of vision have changed? Check all that apply.*

Near/ReadingComputer/Arm's LengthDistance
Which eye is affected?*

Right EyeLeft EyeBoth Eyes
How long ago did this problem start?*

1 day1 week2 weeks1 month
Have you noticed your vision looks cloudy or hazy?*

NoYes
Do you have difficulty driving at night?*

NoYes
Are you bothered by glare (from bright sunlight or bright lights at night)?*

NoYes
Do you have difficulty reading traffic and/or street signs or store signs?*

NoYes
Do you have difficulty seeing in poor or dim light?*

NoYes

Please Answer These Questions Regarding Glaucoma
Has your vision changed?*

NoYes
What range(s) of vision have changed? Check all that apply.*

Near/ReadingComputer/Arm's LengthDistance
Which eye is affected?*

Right EyeLeft EyeBoth Eyes
How long ago did this problem start?*

1 day1 week2 weeks1 month
Are you using any Prescription Eye Drops?*

NoYes
Please list all eye drops here:
Optional: Take a photo of your eye drop bottles showing the names of each one *ONLY WORKS IF YOU ARE USING A CELLPHONE WITH A CAMERA
Have you had any side effects from your Eye Drops? Check all that apply.*

Stinging/burning upon application of dropRednessWatery EyesSwollen EyesDrynessForeign Body SensationNONE
Do you need any refills of your Eye Drops or medications prescribed by Kapolei Eye Care?*

NoYes
Where is your preferred pharmacy?*
Ex: Longs Kapolei
Do you sometimes forget to put in your eye drops?*

NoYes
How many times a week do you miss or forget to put in your eye drops?*

Once a week2 times a week3 to 5 times a week
Please Answer These Questions Regarding Surgery Post-Op

for surgeries done at the Eye Surgery Center of Hawaii
What kind of surgery did you have?*

Cataract SurgeryPterygium SurgeryEyelid SurgeryLaser Eye Surgery
Which eye did you have surgery on?*

Right EyeLeft EyeBoth Eyes

Have you been using your post-op eye drops?*

NoYes
Have you had any side effects from your Eye Drops? Check all that apply.*

Stinging/burning upon application of dropRednessWatery EyesSwollen EyesDrynessForeign Body SensationNONE
Are you experiencing any pain or irritation?*

NoYes
Describe any sensation(s) you may be having. Check all that apply.

AchingBurningIrritatingItchyDull PainSharp PainThrobbing PainTenderUncomfortable
Please Answer These Questions Regarding Sudden Blurry Vision or Loss of Vision
What range(s) of vision have changed? Check all that apply.*

Near/ReadingComputer/Arm's LengthDistance
Which eye is affected?*

Right EyeLeft EyeBoth Eyes
How long ago did this problem start?*

1 day1 week2 weeks1 month
Status of problem since it started:*

Remains unchangedImprovedMildModerateSevereWorseDisabling
When does your problem occur?*

MorningsNight-timeOccasionalConstantWeeklyMonthlySeasonalComes and goes
Describe any sensation(s) you may be having. Check all that apply.

AchingBurningIrritatingItchyDull PainSharp PainThrobbing PainTenderUncomfortable
Do you have any distortion in your vision? (Ex: straight lines look wavy)*

NoYes
Do you have any new or an increase of floaters?*

NoYes
Have you recently seen flashes in your vision?*

NoYes
Have you noticed any shadows in your peripherals (side vision)?*

NoYes
Have you noticed any double vision?*

NoYes

Please Answer These Questions Regarding Allergies (Redness, Itching, Tearing, Discharge)
Which eye is affected?*

Right EyeLeft EyeBoth Eyes
How long ago did this problem start?*

1 day1 week2 weeks1 month
Status of problem since it started:*

Remains unchangedImprovedMildModerateSevereWorseDisabling
When does your problem occur?*

MorningsNight-timeOccasionalConstantWeeklyMonthlySeasonalComes and goes
Describe any sensation(s) you may be having. Check all that apply.

AchingBurningIrritatingItchyDull PainSharp PainThrobbing PainTenderUncomfortable
Do you have redness?*

NoYes
Are your eyes itchy?*

NoYes
Do you have discharge?*

NoYes
What does your discharge look like? Check all that apply.*

WateryMucousStickyWhiteYellow-greenCrusty
Do you have an increase in tearing?*

NoYes
Are you using any eye drops? Ex: Artificial Tears, Visine, Clear Eyes, etc.*

NoYes
Please list all eye drops you are using here:
Optional: Take a photo of your eye drop bottles showing the names of each one *ONLY WORKS IF YOU ARE USING A CELLPHONE WITH A CAMERA
How often are you using these eye drops?*

Once a day2 times a day3 times a day4 times a dayAs Needed

Please Answer These Questions Regarding Dryness
Which eye is affected?*

Right EyeLeft EyeBoth Eyes
How long ago did this problem start?*

1 day1 week2 weeks1 month
Status of problem since it started:*

Remains unchangedImprovedMildModerateSevereWorseDisabling
When does your problem occur?*

MorningsNight-timeOccasionalConstantWeeklyMonthlySeasonalComes and goes
Describe any sensation(s) you may be having. Check all that apply.

AchingBurningIrritatingItchyDull PainSharp PainThrobbing PainTenderUncomfortable
Do you wear contacts?*

NoYes
What kind of contacts do you wear?*

Soft lensesRGP (Rigid Gas Permeable)CRT (Corneal Refractive Therapy)Scleral Lenses
How often do you replace your contact lenses?*

DailyEvery 2 WeeksMonthlyQuarterly (every 3-4 months)
Are you experiencing any dryness while wearing your contacts?*

NoYes
Do you have a history of Dry Eyes?*

NoYes
Are you using Gentle Cleanser or a similar product to cleanse your eyelids?*

NoYes
How often are you using it?*

Once a day2 times a dayOnce a week2-3 times a weekOccasionally
Are you using a Warm Compress?*

NoYes
How often are you using it?*

Once a day2 times a dayOnce a week2-3 times a weekOccasionally
Are you taking Omega-3 Vitamins?*

NoYes
Are you in air conditioning often?*

NoYes

Please Answer These Questions Regarding Foreign Body

(something stuck in eye or sensation of something in eye)
Has your vision changed?*

NoYes
What range(s) of vision have changed? Check all that apply.*

Near/ReadingComputer/Arm's LengthDistance
Please explain how the foreign body may have gotten stuck in your eye. Be as specific as possible.*
Which eye is affected?*

Right EyeLeft EyeBoth Eyes
How long ago did this problem start?*

1 day1 week2 weeks1 month
Status of problem since it started:*

Remains unchangedImprovedMildModerateSevereWorseDisabling
When does your problem occur?*

MorningsNight-timeOccasionalConstantWeeklyMonthlySeasonalComes and goes
Describe any sensation(s) you may be having. Check all that apply.

AchingBurningIrritatingItchyDull PainSharp PainThrobbing PainTenderUncomfortable
Did this problem start while you were at work?*

NoYes
Will you be filing a Worker's Compensation claim?*

NoYes

Please Answer These Questions Regarding Headaches
How long ago did this problem start?*

1 day1 week2 weeks1 month
Status of problem since it started:*

Remains unchangedImprovedMildModerateSevereWorseDisabling
When does your problem occur?*

MorningsNight-timeOccasionalConstantWeeklyMonthlySeasonalComes and goes
Have you been drinking a lot of caffeine?*

NoYes
Are you experiencing a higher level of stress lately?*

NoYes
Are you sleeping well?*

NoYes
Have you noticed any double vision?*

NoYes
What type of headache symptoms do you get? Check all that apply.*

PressureSqueezingStabbingBurningDull
Location of headaches. Check all that apply*

Top of HeadNeckBehind the eye(s)ForeheadTemples
How long do your headaches last?*

15 to 30 mins30 mins to 1 hr1 to 2 hours3 hours or more
Do you take any pain relief or migraine medication when you get headaches?*

NoYes

Please Answer These Questions Regarding Eye Pain
Which eye is affected?*

Right EyeLeft EyeBoth Eyes
How long ago did this problem start?*

1 day1 week2 weeks1 month
Status of problem since it started:*

Remains unchangedImprovedMildModerateSevereWorseDisabling
When does your problem occur?*

MorningsNight-timeOccasionalConstantWeeklyMonthlySeasonalComes and goes
Describe any sensation(s) you may be having. Check all that apply.

AchingBurningIrritatingItchyDull PainSharp PainThrobbing PainTenderUncomfortable

Please Answer These Questions Regarding Sensitivity to Light
Which eye is affected?*

Right EyeLeft EyeBoth Eyes
How long ago did this problem start?*

1 day1 week2 weeks1 month
Status of problem since it started:*

Remains unchangedImprovedMildModerateSevereWorseDisabling
When does your problem occur?*

MorningsNight-timeOccasionalConstantWeeklyMonthlySeasonalComes and goes
Describe any sensation(s) you may be having. Check all that apply.

AchingBurningIrritatingItchyDull PainSharp PainThrobbing PainTenderUncomfortable
Do you have any distortion in your vision? (Ex: straight lines look wavy)*

NoYes
Have you noticed any double vision?*

NoYes

Please Answer These Questions Regarding Flashes and Floaters
Which eye is affected?*

Right EyeLeft EyeBoth Eyes
How long ago did this problem start?*

1 day1 week2 weeks1 month
Status of problem since it started:*

Remains unchangedImprovedMildModerateSevereWorseDisabling
When does your problem occur?*

MorningsNight-timeOccasionalConstantWeeklyMonthlySeasonalComes and goes
Describe any sensation(s) you may be having. Check all that apply.

AchingBurningIrritatingItchyDull PainSharp PainThrobbing PainTenderUncomfortable
Do you have any distortion in your vision? (Ex: straight lines look wavy)*

NoYes
Have you noticed any double vision?*

NoYes

Please Answer These Questions Regarding Spasm
Which eye is affected?*

Right EyeLeft EyeBoth Eyes
How long ago did this problem start?*

1 day1 week2 weeks1 month
Status of problem since it started:*

Remains unchangedImprovedMildModerateSevereWorseDisabling
When does your problem occur?*

MorningsNight-timeOccasionalConstantWeeklyMonthlySeasonalComes and goes
Describe any sensation(s) you may be having. Check all that apply.

AchingBurningIrritatingItchyDull PainSharp PainThrobbing PainTenderUncomfortable
Have you ever had botox injections for your spasm(s)?*

NoYes
Did the botox injections improve your spasm(s)?*

NoYesSomewhat
Have you been drinking a lot of caffeine?*

NoYes
Are you experiencing a higher level of stress lately?*

NoYes
Are you sleeping well?*

NoYes

Please Answer These Questions Regarding Growth
Location of Growth. Check all areas that apply.*

On the Right EyeRight Upper EyelidRight Lower EyelidOn the Left EyeLeft Upper EyelidLeft Lower Eyelid
How long ago did this problem start?*

1 day1 week2 weeks1 month
Has the growth grown since you first noticed it?*

Remains unchangedImproved: getting smallerWorse: grown larger
Describe any sensation(s) you may be having. Check all that apply.

AchingBurningIrritatingItchyDull PainSharp PainThrobbing PainTenderUncomfortable
Are you using any eye drops?*

NoYes
Please list all eye drops you are using here:*
Optional: Take a photo of your eye drop bottles showing the names of each one *ONLY WORKS IF YOU ARE USING A CELLPHONE WITH A CAMERA
How often are you using these eye drops?*

Once a day2 times a day3 times a day4 times a dayAs Needed
Are you using a warm or cold compress?*

Warm CompressCold CompressNeither
How often are you using it?*

Once a day2 times dayOnce a week2 to 3 times a weekOccasionally
Please Answer These Questions Regarding Droopy Eyelid(s)
Which eye is affected?*

Right EyeLeft EyeBoth Eyes
How long ago did this problem start?*

1 day1 week2 weeks1 month
Status of problem since it started:*

Remains unchangedImprovedMildModerateSevereWorseDisabling
Do your eyes feel heavy or tired?*

NoYes
Are your eyelids blocking your vision?*

NoYes
Do you have to open your eyes wider to see better?*

NoYes
Have you ever had to physically lift up your eyelids to see better?*

NoYes

Please Answer These Questions Regarding Trauma/Eye Injury
Please explain what happened. Be as specific as possible.*
Which eye is affected?*

Right EyeLeft EyeBoth Eyes
How long ago did this problem start?*

1 day1 week2 weeks1 month
Status of problem since it started:*

Remains unchangedImprovedMildModerateSevereWorseDisabling
When does your problem occur?*

MorningsNight-timeOccasionalConstantWeeklyMonthlySeasonalComes and goes
Describe any sensation(s) you may be having. Check all that apply.

AchingBurningIrritatingItchyDull PainSharp PainThrobbing PainTenderUncomfortable
Did this problem start while you were at work?*

NoYes
Will you be filing a Worker's Compensation claim?*

NoYes

Please Answer These Questions Regarding Your Eye Problem
Please explain your eye problem here. Be as specific as possible.*
Which eye is affected?*

Right EyeLeft EyeBoth Eyes
How long ago did this problem start?*

1 day1 week2 weeks1 month
Status of problem since it started:*

Remains unchangedImprovedMildModerateSevereWorseDisabling
When does your problem occur?*

MorningsNight-timeOccasionalConstantWeeklyMonthlySeasonalComes and goes
Describe any sensation(s) you may be having. Check all that apply.

AchingBurningIrritatingItchyDull PainSharp PainThrobbing PainTenderUncomfortable
Did this problem start while you were at work?*

NoYes
Will you be filing a Worker's Compensation claim?*

NoYes

Are there any other questions or concerns you might have that you would like your Doctor to address during your appointment?

NoYes
Please type your questions or concerns here:
Review of Systems and Social History
Do you have problems with any of these systems? Check all that apply.*

Fever, weight loss or gainEar, Nose, Throat, MouthCardiovascular (heart, hypertension, etc.)Respiratory (asthma, emphysema, etc.)GastrointestinalGenital, Kidney, BladderMuscles, Bones, Joints (arthritis, etc.)Skin (rash, itching, skin cancer, etc.)Neurological (Alzheimer's Disease, epilepsy/seizures, bell's palsy, etc.)Psychiatric (anxiety, depression, etc.)Endocrine (diabetes, hypothyroid, etc.)Blood/Lymph (anemia, cholesterol, etc.)Allergic/Immunologic (allergies, lupus, etc.)PregnantNursingNONE
Do you drink alcohol?*

NoOccasional1 per day2-3 per day4+ per day
Do you smoke tobacco?*

NoOccasional1/2 pack per day1 pack per day1+ pack per day
Do you use illegal drugs?*

NoYes
COVID-19 Questionnaire
Have you had any flu like symptoms within the past 14 days? Check all that apply.*

FeverSore ThroatCoughDiarrheaEye InfectionChillsRunny NoseBody AchesRespiratory/Breathing IssueLoss of Taste and/or SmellNONE
Have you spoken to or seen your Primary Care Physician about it?*

NoYes
Have you been tested for COVID-19?*

NoYes
When did you get tested?*

MonthDayYear
What was your result?*

PositiveNegative
Have you or any member of your household traveled outside of Hawaii within the past 14 days?*

NoYes
Did you or your household member quarantine upon return?*

NoYes
When was quarantine completed?*

MonthDayYear
Have you been tested for COVID-19?*

NoYes
When did you get tested?*

MonthDayYear
What was your result?*

PositiveNegative
Have you or any member of your household been in close contact with anyone that has test POSITIVE for COVID-19?*

NoYes
Have you been tested for COVID-19?*

NoYes
When did you get tested?*

MonthDayYear
What was your result?*

PositiveNegative
Should be Empty:

Patient Intake Form

Please Answer These Questions Regarding Your Vision and Eye Health

Please Answer These Questions Regarding Cataracts

Please Answer These Questions Regarding Glaucoma

Please Answer These Questions Regarding Surgery Post-Op

Please Answer These Questions Regarding Sudden Blurry Vision or Loss of Vision

Please Answer These Questions Regarding Allergies (Redness, Itching, Tearing, Discharge)

Please Answer These Questions Regarding Dryness

Please Answer These Questions Regarding Foreign Body

Please Answer These Questions Regarding Headaches

Please Answer These Questions Regarding Eye Pain

Please Answer These Questions Regarding Sensitivity to Light

Please Answer These Questions Regarding Flashes and Floaters

Please Answer These Questions Regarding Spasm

Please Answer These Questions Regarding Growth

Please Answer These Questions Regarding Droopy Eyelid(s)

Please Answer These Questions Regarding Trauma/Eye Injury

Please Answer These Questions Regarding Your Eye Problem

Review of Systems and Social History

COVID-19 Questionnaire