New Patient Questionnaire

Patient First Name

Patient Last Name

Preferred Phone

Other Phone

Date of Birth

SSN

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Email Address

Gender

Female Male

How did you hear about us?

If referred, who may we thank?

Guardian (if applicable)

Occupation

Select the appropriate option:

Race

Ethnicity

Preferred Language

Please check appropriate answers and fill in blanks:

Constitutional

Fever, Weight Loss/Gain

Yes No Unsure

Cancer

Yes No Unsure

Ear, Nose, Mouth, Throat

Dry Throat/Mouth

Yes No Unsure

Hearing Loss

Yes No Unsure

Sinusitis

Yes No Unsure

Neurological

Seizures/Epilepsy

Yes No Unsure

Tension Headaches

Yes No Unsure

Migraines

Yes No Unsure

Tumor

Yes No Unsure

Multiple Sclerosis

Yes No Unsure

Psychiatric

Anxiety/Depression

Yes No Unsure

Other

Yes No Unsure

Vascular/Cardiovascular

Heart Disease

Yes No Unsure

High Blood Pressure

Yes No Unsure

Stroke

Yes No Unsure

Respiratory

Asthma

Yes No Unsure

Sleep Apnea

Yes No Unsure

Emphysema

Yes No Unsure

Chronic Bronchitis

Yes No Unsure

Gastrointestinal

Acid Reflux

Yes No Unsure

Crohn's Disease

Yes No Unsure

Genitourinary

Pregnant

Yes No Unsure

Nursing

Yes No Unsure

Prostate Disease

Yes No Unsure

Bones/Joints/Muscles

Shingles/Herpes Zoste

Yes No Unsure

Cold Sores/Herpes

Yes No Unsure

Simplex

Yes No Unsure

Muscle/Joint Pain

Yes No Unsure

Integumentary

Anxiety/Depression

Yes No Unsure

Cold Sores/Herpes

Yes No Unsure

Rosacea

Yes No Unsure

Endocrine

Type 1 Diabetes

Yes No Unsure

Type 2 Diabetes

Yes No Unsure

Cold Sores/Herpes

Yes No Unsure

Lymphatic/Hematologic

Asthma

Yes No Unsure

Sleep Apnea

Yes No Unsure

Allergic/Immunologic

Seasonal Allergies

Yes No Unsure

Sjorgren's Syndrome

Yes No Unsure

Lupus

Yes No Unsure

If you have a condition not listed, please explain, and list any medications you are taking (include oral contraceptives, aspirin, over-the-counter medication, & home remedies):

Do you have any allergies to medication?

YesNo

If yes, explain

Have you ever been exposed to or infected with:

GonorrheaHepatitisHIV/AIDSSyphilis

Ocular History: Please check reason(s) for visit

Loss of Vision

Yes No Unsure

BlurredVision

Yes No Unsure

Distorted Vision/Halos

Yes No Unsure

Loss of Side Vision

Yes No Unsure

Double Vision

Yes No Unsure

Glare/Light Sensitivity

Yes No Unsure

Eye Pain or Soreness

Yes No Unsure

Chronic Infection of Eye or Lid

Yes No Unsure

Sties or Chalazion

Yes No Unsure

Flashes/Floaters in Vision

Yes No Unsure

Retinal Disease

Yes No Unsure

Eye Injury

Yes No Unsure

Dryness

Yes No Unsure

Mucous Discharge

Yes No Unsure

Redness

Yes No Unsure

Sandy or Gritty Feeling

Yes No Unsure

Itching

Yes No Unsure

Burning

Yes No Unsure

Foreign Body Sensation

Yes No Unsure

Excess Tearing/Watering

Yes No Unsure

Glaucoma

Yes No Unsure

Cataract

Yes No Unsure

Lazy Eye

Yes No Unsure

Crossed Eyes

Yes No Unsure

If you answered "Yes" to any of the above, or have a condition not listed, please explain and list medications/drops:

Family History

Please note any family history (parents, grandparents, siblings, children…living or deceased) for the following conditions:

Medical Condition

Cancer

Yes No Unsure

Relationship

Diabetes

Yes No Unsure

Relationship

High Blood Pressure

Yes No Unsure

Relationship

Thyroid Disease

Yes No Unsure

Relationship

Heart Attack

Yes No Unsure

Relationship

Stroke

Yes No Unsure

Relationship

Ocular Condition

Cataract

Yes No Unsure

Relationship

Macular Degeneration

Yes No Unsure

Relationship

Glaucoma

Yes No Unsure

Relationship

Crossed Eyes

Yes No Unsure

Relationship

Amblyopia

Yes No Unsure

Relationship

Retinal Detachment

Yes No Unsure

Relationship

Social History

This information is kept strictly confidential.

Do you drive?

Yes No

If yes, do you have visual difficulty when driving?

Yes No

If yes, please describe:

Do you drink alcohol?

Yes No

If yes, type/amount/how long

Do you use tobacco products?

Yes No

If yes, type/amount/how long

Do you use illegal drugs?

Yes No

If yes, type/amount/how long

Does the patient have any learning or behavioral disabilities?

Yes No Unsure

Please explain:

Glasses/Contact Lens History

Do you wear glasses?

Yes No

Are they for:

Full timeReadingComputerDriving

Do you wear contact lenses?

Yes No

Are they comfortable?

Yes No

Type of contact lenses:

SoftRigidExtended WearOther

How often do you dispose of them?

Brand of contact lenses:

How many hours a day do you usually wear them?

Privacy Policy

Health Information Protection

I have read and agree to the Privacy policy

Thank you. We'll connect with you shortly to confirm your appointment.

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New Patient Questionnaire