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 Name
Last Name
Date Of Birth
*
/
Month
/
Day
Year
Date Picker Icon
Are there any changes to your personal information? ex: address, phone number, email, PCP
*
No changes
Yes *Please fill out the fields below
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
-
Area Code
Phone Number
Home Phone Number
-
Area Code
Phone Number
Preferred Contact Number
Please Select One
Cell Phone
Home Phone
May We Contact You Through Email?
*
Yes
No
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 changes
Yes *Please fill out the fields below
Primary Insurance
Patient's Relationship To Subscriber:
Self *Skip Subscriber Name & DOB question
Spouse
Child
Partner
Other
Subscriber's Name
First Name
Last Name
Subscriber's Date of Birth
-
Month
-
Day
Year
Date Picker Icon
Subscriber ID#
Secondary Insurance
Patient's Relationship To Subscriber:
Self *Skip Subscriber Name & DOB question
Spouse
Child
Partner
Other
Subscriber's Name
First Name
Last Name
Subscriber's Date of Birth
-
Month
-
Day
Year
Date Picker Icon
Subscriber ID#
Are you taking any NEW Medications or Supplements since your last visit with us?
*
No changes
Yes
Please list all NEW Medications or Supplements here:
Are you using any Over-The-Counter eye drops? Ex: Artificial Tears, Visine, Clear Eyes, etc.
*
No
Yes
Please list all Over-The-Counter eye drops you are using here:
How often are you using these eye drops?
Once a day
2 times a day
3 times a day
4 times a day
As Needed
Other
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)
Cataracts
Glaucoma
Surgery Post-Op (for surgeries done at the Eye Surgery Center of Hawaii)
Sudden Blurry Vision or Loss of Vision
Allergies (Redness, Itching, Tearing, Discharge)
Dryness
Foreign Body (something stuck in eye or sensation of something in eye)
Headaches
Eye Pain
Sensitivity to Light
Flashes and/or Floaters
Spasm
Growth
Droopy Eyelid(s)
Trauma/Eye Injury
Other
Please Answer These Questions Regarding Your Vision and Eye Health
Have you been diagnosed with Diabetes?
*
No
Yes
Other
Do you know what your last A1C Level was?
*
No
Yes
What was your last A1C Level?
*
Ex: 6.0%
Do you check your Blood Sugar at home?
*
No
Yes
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?
*
No
Yes
Which eye is affected?
*
Right Eye
Left Eye
Both Eyes
What range(s) of vision have changed? Check all that apply.
*
Near/Reading
Computer/Arm's Length
Distance
Do you wear glasses?
*
No
Yes
What kind of lenses do you have?
Distance only
Reading only
Bifocal (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 old
2 years old
3-5 years old
Other
Do you wear contacts?
*
No
Yes
What kind of contacts do you wear?
*
Soft lenses
RGP (Rigid Gas Permeable)
CRT (Corneal Refractive Therapy)
Scleral Lenses
How often do you replace your contact lenses?
*
Daily
Every 2 Weeks
Monthly
Quarterly (every 3-4 months)
Other
Are you experiencing any dryness while wearing your contacts?
*
No
Yes
Do you have a history of dry eyes or recently experienced any dryness?
*
No
Yes
Are you using Gentle Cleanser or a similar product to cleanse your eyelids?
*
No
Yes
How often are you using it?
*
Once a day
2 times a day
Once a week
2 to 3 times a week
Occasionally
Other
Are you using using a Warm Compress?
*
No
Yes
How often are you using it?
*
Once a day
2 times a day
Once a week
2 to 3 times a week
Occasionally
Other
Are you taking Omega-3 Fish Oil Vitamins?
*
No
Yes
Are you in air conditioning often?
*
No
Yes
How much is the dryness bothering you?
*
1
2
3
4
5
6
7
8
9
10
MIld
Severe
1 is MIld, 10 is Severe
Please Answer These Questions Regarding Cataracts
Has your vision changed?
*
No
Yes
What range(s) of vision have changed? Check all that apply.
*
Near/Reading
Computer/Arm's Length
Distance
Which eye is affected?
*
Right Eye
Left Eye
Both Eyes
How long ago did this problem start?
*
1 day
1 week
2 weeks
1 month
Other
Have you noticed your vision looks cloudy or hazy?
*
No
Yes
Do you have difficulty driving at night?
*
No
Yes
Are you bothered by glare (from bright sunlight or bright lights at night)?
*
No
Yes
Do you have difficulty reading traffic and/or street signs or store signs?
*
No
Yes
Do you have difficulty seeing in poor or dim light?
*
No
Yes
How much are these symptoms bothering you?
*
1
2
3
4
5
6
7
8
9
10
MIld
Severe
1 is MIld, 10 is Severe
Please Answer These Questions Regarding Glaucoma
Has your vision changed?
*
No
Yes
What range(s) of vision have changed? Check all that apply.
*
Near/Reading
Computer/Arm's Length
Distance
Which eye is affected?
*
Right Eye
Left Eye
Both Eyes
How long ago did this problem start?
*
1 day
1 week
2 weeks
1 month
Other
Are you using any Prescription Eye Drops?
*
No
Yes
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 drop
Redness
Watery Eyes
Swollen Eyes
Dryness
Foreign Body Sensation
NONE
Other
Do you need any refills of your Eye Drops or medications prescribed by Kapolei Eye Care?
*
No
Yes
Where is your preferred pharmacy?
*
Ex: Longs Kapolei
Do you sometimes forget to put in your eye drops?
*
No
Yes
How many times a week do you miss or forget to put in your eye drops?
*
Once a week
2 times a week
3 to 5 times a week
Other
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 Surgery
Pterygium Surgery
Eyelid Surgery
Laser Eye Surgery
Which eye did you have surgery on?
*
Right Eye
Left Eye
Both Eyes
Rate your vision after surgery (1: Worse than before/Very blurry, 10: Excellent/Very clear!)
*
1
2
3
4
5
6
7
8
9
10
Very blurry
Very Clear
1 is Very blurry, 10 is Very Clear
Have you been using your post-op eye drops?
*
No
Yes
Have you had any side effects from your Eye Drops? Check all that apply.
*
Stinging/burning upon application of drop
Redness
Watery Eyes
Swollen Eyes
Dryness
Foreign Body Sensation
NONE
Other
Are you experiencing any pain or irritation?
*
No
Yes
Describe any sensation(s) you may be having. Check all that apply.
Aching
Burning
Irritating
Itchy
Dull Pain
Sharp Pain
Throbbing Pain
Tender
Uncomfortable
Other
Please Answer These Questions Regarding Sudden Blurry Vision or Loss of Vision
What range(s) of vision have changed? Check all that apply.
*
Near/Reading
Computer/Arm's Length
Distance
Which eye is affected?
*
Right Eye
Left Eye
Both Eyes
How long ago did this problem start?
*
1 day
1 week
2 weeks
1 month
Other
Status of problem since it started:
*
Remains unchanged
Improved
Mild
Moderate
Severe
Worse
Disabling
When does your problem occur?
*
Mornings
Night-time
Occasional
Constant
Weekly
Monthly
Seasonal
Comes and goes
Other
Describe any sensation(s) you may be having. Check all that apply.
Aching
Burning
Irritating
Itchy
Dull Pain
Sharp Pain
Throbbing Pain
Tender
Uncomfortable
Other
Do you have any distortion in your vision? (Ex: straight lines look wavy)
*
No
Yes
Do you have any new or an increase of floaters?
*
No
Yes
Have you recently seen flashes in your vision?
*
No
Yes
Have you noticed any shadows in your peripherals (side vision)?
*
No
Yes
Have you noticed any double vision?
*
No
Yes
How much are these symptoms bothering you?
*
1
2
3
4
5
6
7
8
9
10
Mild
Severe
1 is Mild, 10 is Severe
Please Answer These Questions Regarding Allergies (Redness, Itching, Tearing, Discharge)
Which eye is affected?
*
Right Eye
Left Eye
Both Eyes
How long ago did this problem start?
*
1 day
1 week
2 weeks
1 month
Other
Status of problem since it started:
*
Remains unchanged
Improved
Mild
Moderate
Severe
Worse
Disabling
When does your problem occur?
*
Mornings
Night-time
Occasional
Constant
Weekly
Monthly
Seasonal
Comes and goes
Other
Describe any sensation(s) you may be having. Check all that apply.
Aching
Burning
Irritating
Itchy
Dull Pain
Sharp Pain
Throbbing Pain
Tender
Uncomfortable
Other
Do you have redness?
*
No
Yes
Are your eyes itchy?
*
No
Yes
Do you have discharge?
*
No
Yes
What does your discharge look like? Check all that apply.
*
Watery
Mucous
Sticky
White
Yellow-green
Crusty
Other
Do you have an increase in tearing?
*
No
Yes
Are you using any eye drops? Ex: Artificial Tears, Visine, Clear Eyes, etc.
*
No
Yes
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 day
2 times a day
3 times a day
4 times a day
As Needed
Other
How much are these symptoms bothering you?
*
1
2
3
4
5
6
7
8
9
10
Mild
Severe
1 is Mild, 10 is Severe
Please Answer These Questions Regarding Dryness
Which eye is affected?
*
Right Eye
Left Eye
Both Eyes
How long ago did this problem start?
*
1 day
1 week
2 weeks
1 month
Other
Status of problem since it started:
*
Remains unchanged
Improved
Mild
Moderate
Severe
Worse
Disabling
When does your problem occur?
*
Mornings
Night-time
Occasional
Constant
Weekly
Monthly
Seasonal
Comes and goes
Other
Describe any sensation(s) you may be having. Check all that apply.
Aching
Burning
Irritating
Itchy
Dull Pain
Sharp Pain
Throbbing Pain
Tender
Uncomfortable
Other
Do you wear contacts?
*
No
Yes
What kind of contacts do you wear?
*
Soft lenses
RGP (Rigid Gas Permeable)
CRT (Corneal Refractive Therapy)
Scleral Lenses
How often do you replace your contact lenses?
*
Daily
Every 2 Weeks
Monthly
Quarterly (every 3-4 months)
Other
Are you experiencing any dryness while wearing your contacts?
*
No
Yes
Do you have a history of Dry Eyes?
*
No
Yes
Are you using Gentle Cleanser or a similar product to cleanse your eyelids?
*
No
Yes
How often are you using it?
*
Once a day
2 times a day
Once a week
2-3 times a week
Occasionally
Other
Are you using a Warm Compress?
*
No
Yes
How often are you using it?
*
Once a day
2 times a day
Once a week
2-3 times a week
Occasionally
Other
Are you taking Omega-3 Vitamins?
*
No
Yes
Are you in air conditioning often?
*
No
Yes
How much are these symptoms bothering you?
*
1
2
3
4
5
6
7
8
9
10
Mild
Severe
1 is Mild, 10 is Severe
Please Answer These Questions Regarding Foreign Body
(something stuck in eye or sensation of something in eye)
Has your vision changed?
*
No
Yes
What range(s) of vision have changed? Check all that apply.
*
Near/Reading
Computer/Arm's Length
Distance
Please explain how the foreign body may have gotten stuck in your eye. Be as specific as possible.
*
Which eye is affected?
*
Right Eye
Left Eye
Both Eyes
How long ago did this problem start?
*
1 day
1 week
2 weeks
1 month
Other
Status of problem since it started:
*
Remains unchanged
Improved
Mild
Moderate
Severe
Worse
Disabling
When does your problem occur?
*
Mornings
Night-time
Occasional
Constant
Weekly
Monthly
Seasonal
Comes and goes
Other
Describe any sensation(s) you may be having. Check all that apply.
Aching
Burning
Irritating
Itchy
Dull Pain
Sharp Pain
Throbbing Pain
Tender
Uncomfortable
Other
Did this problem start while you were at work?
*
No
Yes
Will you be filing a Worker's Compensation claim?
*
No
Yes
How much are these symptoms bothering you?
*
1
2
3
4
5
6
7
8
9
10
Mild
Severe
1 is Mild, 10 is Severe
Please Answer These Questions Regarding Headaches
How long ago did this problem start?
*
1 day
1 week
2 weeks
1 month
Other
Status of problem since it started:
*
Remains unchanged
Improved
Mild
Moderate
Severe
Worse
Disabling
When does your problem occur?
*
Mornings
Night-time
Occasional
Constant
Weekly
Monthly
Seasonal
Comes and goes
Other
Have you been drinking a lot of caffeine?
*
No
Yes
Are you experiencing a higher level of stress lately?
*
No
Yes
Are you sleeping well?
*
No
Yes
Have you noticed any double vision?
*
No
Yes
What type of headache symptoms do you get? Check all that apply.
*
Pressure
Squeezing
Stabbing
Burning
Dull
Other
Location of headaches. Check all that apply
*
Top of Head
Neck
Behind the eye(s)
Forehead
Temples
Other
How long do your headaches last?
*
15 to 30 mins
30 mins to 1 hr
1 to 2 hours
3 hours or more
Other
Do you take any pain relief or migraine medication when you get headaches?
*
No
Yes
How much are these symptoms bothering you?
*
1
2
3
4
5
6
7
8
9
10
Mild
Severe
1 is Mild, 10 is Severe
Please Answer These Questions Regarding Eye Pain
Which eye is affected?
*
Right Eye
Left Eye
Both Eyes
How long ago did this problem start?
*
1 day
1 week
2 weeks
1 month
Other
Status of problem since it started:
*
Remains unchanged
Improved
Mild
Moderate
Severe
Worse
Disabling
When does your problem occur?
*
Mornings
Night-time
Occasional
Constant
Weekly
Monthly
Seasonal
Comes and goes
Other
Describe any sensation(s) you may be having. Check all that apply.
Aching
Burning
Irritating
Itchy
Dull Pain
Sharp Pain
Throbbing Pain
Tender
Uncomfortable
Other
How much are these symptoms bothering you?
*
1
2
3
4
5
6
7
8
9
10
Mild
Severe
1 is Mild, 10 is Severe
Please Answer These Questions Regarding Sensitivity to Light
Which eye is affected?
*
Right Eye
Left Eye
Both Eyes
How long ago did this problem start?
*
1 day
1 week
2 weeks
1 month
Other
Status of problem since it started:
*
Remains unchanged
Improved
Mild
Moderate
Severe
Worse
Disabling
When does your problem occur?
*
Mornings
Night-time
Occasional
Constant
Weekly
Monthly
Seasonal
Comes and goes
Other
Describe any sensation(s) you may be having. Check all that apply.
Aching
Burning
Irritating
Itchy
Dull Pain
Sharp Pain
Throbbing Pain
Tender
Uncomfortable
Other
Do you have any distortion in your vision? (Ex: straight lines look wavy)
*
No
Yes
Have you noticed any double vision?
*
No
Yes
How much are these symptoms bothering you?
*
1
2
3
4
5
6
7
8
9
10
Mild
Severe
1 is Mild, 10 is Severe
Please Answer These Questions Regarding Flashes and Floaters
Which eye is affected?
*
Right Eye
Left Eye
Both Eyes
How long ago did this problem start?
*
1 day
1 week
2 weeks
1 month
Other
Status of problem since it started:
*
Remains unchanged
Improved
Mild
Moderate
Severe
Worse
Disabling
When does your problem occur?
*
Mornings
Night-time
Occasional
Constant
Weekly
Monthly
Seasonal
Comes and goes
Other
Describe any sensation(s) you may be having. Check all that apply.
Aching
Burning
Irritating
Itchy
Dull Pain
Sharp Pain
Throbbing Pain
Tender
Uncomfortable
Other
Do you have any distortion in your vision? (Ex: straight lines look wavy)
*
No
Yes
Have you noticed any double vision?
*
No
Yes
How much are these symptoms bothering you?
*
1
2
3
4
5
6
7
8
9
10
Mild
Severe
1 is Mild, 10 is Severe
Please Answer These Questions Regarding Spasm
Which eye is affected?
*
Right Eye
Left Eye
Both Eyes
How long ago did this problem start?
*
1 day
1 week
2 weeks
1 month
Other
Status of problem since it started:
*
Remains unchanged
Improved
Mild
Moderate
Severe
Worse
Disabling
When does your problem occur?
*
Mornings
Night-time
Occasional
Constant
Weekly
Monthly
Seasonal
Comes and goes
Other
Describe any sensation(s) you may be having. Check all that apply.
Aching
Burning
Irritating
Itchy
Dull Pain
Sharp Pain
Throbbing Pain
Tender
Uncomfortable
Other
Have you ever had botox injections for your spasm(s)?
*
No
Yes
Did the botox injections improve your spasm(s)?
*
No
Yes
Somewhat
Other
Have you been drinking a lot of caffeine?
*
No
Yes
Are you experiencing a higher level of stress lately?
*
No
Yes
Are you sleeping well?
*
No
Yes
How much are these symptoms bothering you?
*
1
2
3
4
5
6
7
8
9
10
Mild
Severe
1 is Mild, 10 is Severe
Please Answer These Questions Regarding Growth
Location of Growth. Check all areas that apply.
*
On the Right Eye
Right Upper Eyelid
Right Lower Eyelid
On the Left Eye
Left Upper Eyelid
Left Lower Eyelid
Other
How long ago did this problem start?
*
1 day
1 week
2 weeks
1 month
Other
Has the growth grown since you first noticed it?
*
Remains unchanged
Improved: getting smaller
Worse: grown larger
Describe any sensation(s) you may be having. Check all that apply.
Aching
Burning
Irritating
Itchy
Dull Pain
Sharp Pain
Throbbing Pain
Tender
Uncomfortable
Other
Are you using any eye drops?
*
No
Yes
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 day
2 times a day
3 times a day
4 times a day
As Needed
Other
Are you using a warm or cold compress?
*
Warm Compress
Cold Compress
Neither
How often are you using it?
*
Once a day
2 times day
Once a week
2 to 3 times a week
Occasionally
Other
Please Answer These Questions Regarding Droopy Eyelid(s)
Which eye is affected?
*
Right Eye
Left Eye
Both Eyes
How long ago did this problem start?
*
1 day
1 week
2 weeks
1 month
Other
Status of problem since it started:
*
Remains unchanged
Improved
Mild
Moderate
Severe
Worse
Disabling
Do your eyes feel heavy or tired?
*
No
Yes
Are your eyelids blocking your vision?
*
No
Yes
Do you have to open your eyes wider to see better?
*
No
Yes
Have you ever had to physically lift up your eyelids to see better?
*
No
Yes
How much are these symptoms bothering you?
*
1
2
3
4
5
6
7
8
9
10
Mild
Severe
1 is Mild, 10 is Severe
Please Answer These Questions Regarding Trauma/Eye Injury
Please explain what happened. Be as specific as possible.
*
Which eye is affected?
*
Right Eye
Left Eye
Both Eyes
How long ago did this problem start?
*
1 day
1 week
2 weeks
1 month
Other
Status of problem since it started:
*
Remains unchanged
Improved
Mild
Moderate
Severe
Worse
Disabling
When does your problem occur?
*
Mornings
Night-time
Occasional
Constant
Weekly
Monthly
Seasonal
Comes and goes
Other
Describe any sensation(s) you may be having. Check all that apply.
Aching
Burning
Irritating
Itchy
Dull Pain
Sharp Pain
Throbbing Pain
Tender
Uncomfortable
Other
Did this problem start while you were at work?
*
No
Yes
Will you be filing a Worker's Compensation claim?
*
No
Yes
How much are these symptoms bothering you?
*
1
2
3
4
5
6
7
8
9
10
Mild
Severe
1 is Mild, 10 is Severe
Please Answer These Questions Regarding Your Eye Problem
Please explain your eye problem here. Be as specific as possible.
*
Which eye is affected?
*
Right Eye
Left Eye
Both Eyes
How long ago did this problem start?
*
1 day
1 week
2 weeks
1 month
Other
Status of problem since it started:
*
Remains unchanged
Improved
Mild
Moderate
Severe
Worse
Disabling
When does your problem occur?
*
Mornings
Night-time
Occasional
Constant
Weekly
Monthly
Seasonal
Comes and goes
Other
Describe any sensation(s) you may be having. Check all that apply.
Aching
Burning
Irritating
Itchy
Dull Pain
Sharp Pain
Throbbing Pain
Tender
Uncomfortable
Other
Did this problem start while you were at work?
*
No
Yes
Will you be filing a Worker's Compensation claim?
*
No
Yes
How much are these symptoms bothering you?
*
1
2
3
4
5
6
7
8
9
10
Mild
Severe
1 is Mild, 10 is Severe
Are there any other questions or concerns you might have that you would like your Doctor to address during your appointment?
No
Yes
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 gain
Ear, Nose, Throat, Mouth
Cardiovascular (heart, hypertension, etc.)
Respiratory (asthma, emphysema, etc.)
Gastrointestinal
Genital, Kidney, Bladder
Muscles, 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.)
Pregnant
Nursing
NONE
Do you drink alcohol?
*
No
Occasional
1 per day
2-3 per day
4+ per day
Do you smoke tobacco?
*
No
Occasional
1/2 pack per day
1 pack per day
1+ pack per day
Do you use illegal drugs?
*
No
Yes
COVID-19 Questionnaire
Have you had any flu like symptoms within the past 14 days? Check all that apply.
*
Fever
Sore Throat
Cough
Diarrhea
Eye Infection
Chills
Runny Nose
Body Aches
Respiratory/Breathing Issue
Loss of Taste and/or Smell
NONE
Have you spoken to or seen your Primary Care Physician about it?
*
No
Yes
Have you been tested for COVID-19?
*
No
Yes
When did you get tested?
*
-
Month
-
Day
Year
Date Picker Icon
What was your result?
*
Positive
Negative
Have you or any member of your household traveled outside of Hawaii within the past 14 days?
*
No
Yes
Did you or your household member quarantine upon return?
*
No
Yes
When was quarantine completed?
*
-
Month
-
Day
Year
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Have you or any member of your household been in close contact with anyone that has test POSITIVE for COVID-19?
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Have you been tested for COVID-19?
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What was your result?
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