Pacific Eye Clinic
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New Patient Form
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Pacific Eye Clinic
Thank you for completing the questionnaire below. The federal government requires us to complete the following information for compliance with new health record laws. WE DO NOT SHARE YOUR INFORMATION
Patient Name
First
Last
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Native American
Caucasian
Refuse to Specify
Other Race
Primary Care Physician
Preferred Pharmacy
Reason for today's visit
Last Eye Exam
Last Exam Where Eyes Were Dilated
Past Surgeries
Please include date
Major Illnesses
Eg. Diabetes, hypertension
Are you Diabetic?
Yes
No
Blood sugar
mg/dl
Fasting
Random
HbA1C
%
Allergy History
Please include Reaction Date, Allergy and Reaction
Medication
Please include Drug, Mg Strength and Reason for Medication
Diseases
Amblyopia (lazy eye)
Blepharitis
Blindness
Cataract
Color Blindness
Diabetic Retinopathy
Dry Eye Symptoms
Eye Injuries
Glaucoma
Glaucoma Suspect
High Risk Medication
Macular Degeneration
PVD
Retinal Detachment
Strabismus (eye turn)
Other
Amblyopia (lazy eye)
Right Eye
Left Eye
Both
Blepharitis
Right Eye
Left Eye
Both
Blindness
Right Eye
Left Eye
Both
Cataract
Right Eye
Left Eye
Both
Color Blindess
Right Eye
Left Eye
Both
Diabetic Retinopathy
Right Eye
Left Eye
Both
Dry Eye Symptoms
Right Eye
Left Eye
Both
Eye Injuries
Right Eye
Left Eye
Both
Glaucoma
Right Eye
Left Eye
Both
Glaucoma Suspect
Right Eye
Left Eye
Both
High Risk Medication
Right Eye
Left Eye
Both
Macular Degeneration
Right Eye
Left Eye
Both
PVD
Right Eye
Left Eye
Both
Retinal Detachment
Right Eye
Left Eye
Both
Strabismus (Eye Turn)
Right Eye
Left Eye
Both
Other
Current Eye Symptoms
Glare Sensitivity
Headaches
Light Sesitivity
Tired Eyes
Burning
Dryness
Epiphora (Tearing)
Eyelid Swelling
Eye Pain or Soreness
Foreign Body Sensation
Infection of Eye Lid
Itching
Mucous
Drooping Eye Lid
Redness
Sandy or Gritty Feeling
Glare Sensitivity
Which Eye, when did it begin?
Headaches
Which Eye, when did it begin?
Light Sensitivity
Which Eye, when did it begin?
Tired Eyes
Which Eye, when did it begin?
Burning
Which Eye, when did it begin?
Dryness
Which Eye, when did it begin?
Epiphora (Tearing)
Which Eye, when did it begin?
Eyelid Swelling
Which Eye, when did it begin?
Eye Pain or Soreness
Which Eye, when did it begin?
Foreign Body Sensation
Which Eye, when did it begin?
Infection of Eye Lid
Which Eye, when did it begin?
Itching
Which Eye, when did it begin?
Mucous
Which Eye, when did it begin?
Drooping Eye Lid
Which Eye, when did it begin?
Redness
Which Eye, when did it begin?
Sandy or Gritty Feeling
Which Eye, when did it begin?
Visual Symptoms
Blurred Vision Distance
Blurred Vision Near
Distorted Vision
Double Vision
Flashes of Light
Floaters or Spots
Fluctuating Vision
Loss of Central Vision
Loss of Side Vision
Loss of Vision
Other
Blurred Vision Distance
Which Eye, when did it begin?
Blurred Vision Near
Which Eye, when did it begin?
Distorted Vision
Which Eye, when did it begin?
Double Vision
Which Eye, when did it begin?
Flashes of Light
Which Eye, when did it begin?
Floaters of Spots
Which Eye, when did it begin?
Fluctuating Vision
Which Eye, when did it begin?
Loss of Central Vision
Which Eye, when did it begin?
Loss of Side Vision
Which Eye, when did it begin?
Loss of Vision
Which Eye, when did it begin?
Other
Which Eye, when did it begin?
Constitutional Symptoms
Fever
Fatigue
Sleep Disorder/CPAP
Other
Other
Ear, Nose, Throat, Mouth
Hearing Loss
Sinus Disorder
Other
Other
Cardiovascular
Atrial Fibrillation
Heart Disease
Hypertension
Stroke/TIA
Other
Other
Skin
Herpes
Rash/Itching
Rosacea
Shingles
Skin Cancer
Other
Other
Neurological
Multiple Sclerosis
Frequent Headaches
Convulsions/Seizure
Other
Other
Respiratory
Asthma
Emphysema/COPD
Shortness of Breath
Other
Other
Gastrointestinal
Intestinal Conditions
Other
Other
Urinary
Flomax Use
Kidney Disease
Urinary Conditions
Urinary Symptoms
Other
Other
Musculoskeletal
Arthritis
Muscle/Joint/Back Pain
Other
Other
Psychiatric
Memory Loss
Depression
Other
Other
Endocrine
Diabetes
Thyroid Disease
Other
Other
Blood
Anemia
Cholesterol
Other
Other
Allergic/Immunologic
Season Allergies
Lupus
Other
Other
Last Health Exam
Pregnant or Nursing
No
Pregnant
Nursing
Family History
Eye Disease
Amblyopia (Lazy Eye)
Blindness
Cataract
Color Blindness
Eye Tumors
Glaucoma
Glaucoma Suspect
Macular Degeneration
Retinal Detachment
Strabismus (Eye Turn)
Other Eye Conditions
Amblyopia (Lazy Eye)
Relationship to Patient
Blindness
Relationship to Patient
Cataract
Relationship to Patient
Color Blindess
Relationship to Patient
Eye Tumors
Relationship to Patient
Glaucoma
Relationship to Patient
Glaucoma Suspect
Relationship to Patient
Macular Degeneration
Relationship to Patient
Retinal Detachment
Relationship to Patient
Strabismus (Eye Turn)
Relationship to Patient
Other Eye Conditions
Relationship to Patient
Systemic Diseases
Arthritis
Cancer
Diabetes
Heart Disease
High Blood Pressure
Kidney Disease
Lupus
Stroke
Thyroid Disease
Other Diseases
Arthritis
Relationship to Patient
Cancer
Relationship to Patient
Diabetes
Relationship to Patient
Heart Disease
Relationship to Patient
High Blood Pressure
Relationship to Patient
Kidney Disease
Relationship to Patient
Lupus
Relationship to Patient
Stroke
Relationship to Patient
Thyroid Disease
Relationship to Patient
Other Diseases
Relationship to Patient
General Social History
Occupation
Years
Employer
Do you drink alcohol?
No
Occasional
1 per day
2-3 per day
4+ per day
Do you smoke?
No
Occasional
1/2 pk per day
1 pk per day
1+ pk per day
Past Smoker?
Yes
No
When did you quit?
Do you chew tobacco?
Yes
No
Do you use illegal drugs?
Yes
No
Do you use nutritional supplements (vitamins, etc.)?
Yes
No
Do you engage in regular exercise?
Yes
No
Vision Social History
Do you use the computer?
Yes
No
Do you drive?
Yes
No
Have visual difficulty when driving?
Yes
No
Do you have a problem with glare?
Yes
No
Have any problems with night vision?
Yes
No
Spectacles
Do you currently wear glasses?
Yes
No
Since?
Full Time
Part Time
Distance
Close
Glasses Owned
Single Vision
Safety Glasses
Bifocals
Sport Glasses
Trifocals
Progressives
Back-up glasses
Other
Other
Have you had trouble in the past with glasses?
Yes
No
Please explain
Do you wear sunglasses?
Yes
No
Are your sunglasses your current prescription?
Yes
No
Do you need special eyewear?
Computer
Safety Glasses
Occupational
Sports/Hobbies
Contact Lenses
Have you tried to wear contact lenses?
Yes
No
Reason for stopping?
Do you currently wear contact lenses?
Yes
No
Since
Brand of contact lenses
How many hours per day?
How many days per week?
How long do you wear your contact lenses before you toss them for a fresh pair?
What contact lens solution do you use?
Are you interested in trying contact lenses at this time?
Yes
No
Please rate the following on a scale of 1-10, with 1 being POOR and 10 being EXCELLENT
Comfort
Right, Left
Distance Vision
Right, Left
Near Vision
Right, Left
Phone
This field is for validation purposes and should be left unchanged.
