communityeyeassociates.com - New Patient Health History Form

New Patient Health History Form
NEW PATIENT REGISTRATION

Contact Information
Name*

First NameLast Name
Daytime Phone
Please enter a valid phone number.
Mobile Phone
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian Information

(if patient is under 18 years of age)
Name

First NameLast Name
Daytime Phone
Please enter a valid phone number.
Mobile Phone
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Information
Date of Birth

MonthDayYear
Date
The last 4 digits of your SSN
Primary Insurance Information
Provider Name
Provider Phone
Please enter a valid phone number.
Policy/I.D. No.
Group No.
Additional Insurance Information
Provider Name
Provider Phone
Please enter a valid phone number.
Policy/I.D. No.
Add Text Here
Financial Assignment Information
I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.
Acknowledgment of Notice of Privacy Practices (NPP)
Please Select

Yes, I have read or had explained to me by this office the NPP & I wish to continue my care under said terms.No, I have not read this office’s NPP but I was given the opportunity to read it and declined. I wish to continue my care under said terms.The NPP could not be read due to the emergent nature of the care needed.
Signature agreeing to all above terms*

Clear
Print Name*
Date

MonthDayYear
Date
PATIENT HISTORY

Ocular History
Please check any that apply

Amblyopia (lazy eye)Blurred vision at a distanceBlurred vision at nearBurningDouble visionDrooping eyelid(s)DrynessEye pain and/or sorenessFloaters or spotsFluctuating visionForeign body sensationHalosI stopped wearing contact lensesI stopped wearing glassesInfection of eye or lidItchingLoss of peripheral visionLoss of visionMucous dischargeRednessSandy or gritty feelingSensitivity to light/glareTired eyesWatery eyes
Glasses History
What glasses do you own?

Backup pairBifocalsDistanceProgressive lensReadingSafety glassesSingle visionSports glassesSunglassesTrifocalsOther
How many hours per day do you spend using a computer?
Check any that apply

Allergic to nickel (frames)I do not want to wear glassesIncorrect prescriptionNeed spare glassesNeed sunglasses with UVProblems with current glassesProblems with glareProblems with night vision
Contact Lens History
What brand of contacts do you wear?
How old are your current contacts?
How often do you replace them?
What solution do you use for soaking?
What is your typical wearing schedule?
Check any that apply

I want to continue with current brand of contact lensesI want to change brand of contact lensesI want to try contact lensesI do not want to wear contactsIncorrect prescriptionInterested in refractive laser surgeryInterested in non-surgical correctionNeed spare contactsProblems with current contactsWould like to change my eye color
General Medical History

(please answer appropriately)
Allergies (please list)
When (approx.) was your last eye exam?*
Primary Care Provider Name*
Primary Care Provide Phone
Please enter a valid phone number.
Surgeries and dates of procedures
Do you have any of the following?

ArthritisAsthmaCancerDiabetesHeart diseaseHigh cholesterolHIVHypertension (high blood pressure)Migraines/headachesMultiple sclerosis (MS)Other
Referral Information
Why did you visit us?

Referred by your doctorVisited our websiteFound us on social mediaReferred directly
Questions and notes
Should be Empty:

New Patient Health History Form

Guardian Information

Patient Information

Primary Insurance Information

Additional Insurance Information

Financial Assignment Information

Acknowledgment of Notice of Privacy Practices (NPP)

PATIENT HISTORY

Glasses History

Contact Lens History

General Medical History

Referral Information