Eyeclectic Vision Source

Eyeclectic Vision Source

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New Patient Form

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Patient Details
Patient Name*
First Last
Patient Date of Birth*
Is the Patient a Minor?
- No
- Yes
Legal Guardian Name
First Last
Contact Information
Address*
Street Address Address Line 2 City State ZIP Code
Primary Phone*
Mobile Phone
OK to Contact Via Text Message?
Email
Enter Email Confirm Email
Preferred Contact Method
Do You Have an Emergency Contact?
- No
- Yes
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Relationship
Insurance Information
Name of Insurance Company*
Primary Account Holder Name*
Policy Number*
Demographics
Patient Occupation
Patient Gender
Patient Marital Status
Patient Race, Ethnicity
How Did You Hear About Our Office?
Who May We Thank for Referring You?

Exam History
When Was Patient's Last Eye Exam?
Does Patient Currently Wear Glasses?
- Yes
- No
How Often Does Patient Wear Glasses?
- Constantly
- Reading / Computer
- Driving
- Leisure / Fashion only
Does Patient Currently Wear Contacts?
- Yes
- No
Current Contacts Brand
Current Contacts Prescription
Are You Interested in Contacts?
- Yes
- No
Reason for Patient's Visit
Name of Patient's Primary Care Physician
Name of Patient's Primary Care Physician's Practice
Optical & Medical History
Has patient experienced, or been treated for, any of the following? Check all that apply.
Eye Conditions & Disorders
- Cataracts
- Crossed Eye
- Glaucoma
- LASIK or RK
- Lazy Eye
- Macular Degeneration
- Retinal Detachment
- Blurry Vision (Near or Far)
- Burning
- Discharge
- Double Vision
- Dryness
- Excess Tearing/Watering
- Eye Infection
- Eye Pain or Soreness
- Floaters or Spots
- Halos
- Headaches
- Itching
- Light Flashes
- Light Sensitivity
- Redness
- Sandy or Gritty Feeling
- Other
Medical Conditions
- AIDS/HIV
- Allergies
- Arthritis
- Asthma
- Blood/Lymph Disorder
- Cancer
- Diabetes
- Ears, Nose, Throat Conditions
- Gastrointestinal Conditions
- Heart Disease
- High Blood Pressure
- High Cholesterol
- Kidney Disease
- Lupus
- Neurological Conditions
- Psychiatric Disorder
- Seizures
- Skin Conditions
- Stroke
- Thyroid Dysfunction
- Other
Other Medical Conditions
Family History
Has any of patient's family members experienced, or been treated for, any of the following? Check all that apply.
- Arthritis
- Amblyopia
- Stroke
- Glaucoma
- Thyroid Disease
- High Blood Pressure
- Diabetes
- Cancer
- Lupus
- Kidney Disease
- Macular Degeneration
- Retinal Detachment
- Cataract
- Blindness
- Other
Medications & Vitals
Vitamins
Please indicate all recreational and over-the-counter vitamins.
- Aspirin
- Vitamin C
- Vitamin D
- Vitamin E
- Omega-E/Fish Oil
- Glucosamine
- Antihistamine
- Other Vitamins
Current Medications
List all medications and conditions being treated.
Medication Drug Allergies
Please include food, tape, latex, and dyes.
Is Patient Pregnant or Nursing?
- Yes
- No
Does Patient Smoke?
- Yes
- No
- Never
How Many Packs Per Day?
- 1
- 2
- 3
- 4
- 5 +
- Social
Does Patient Consume Alcohol?
- Yes
- No
How Many Drinks Per Week?
- 1
- 2
- 3
- 4
- 5 +
- Social
Email
This field is for validation purposes and should be left unchanged.