New Patient Welcome Form Demographics and Health History

Windward VISION Center

Dr. Gerald M. Matsuda Dr. Stuart Machida Dr. Kari Chang Moses Dr. Shelley Tasaka Dr. Jenny Nguyen
WELCOME TO OUR OFFICE! Please complete this form as accurately as possible.
Name*

First NameMiddle InitialLast NameSuffix
Type a question

Dr.Mr.Mrs.Ms.MissMaster
Nickname
Gender

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Address (if different)
Cell Phone*
Work Phone
Home Phone
Texting Ok?*

YesNo
E-mail*
example@example.com
Preferred method of contact:

EmailPostalPhone
Employer (Or School)
Occupation (Or Grade)
Birthdate*
Marital Status
choose one
Name of Spouse

First NameLast Name
Name of Responsible Person of Account*

NameRelationship
Emergency Contact

NameRelationship
Emergency Contact Phone Number
Referred By:
Race*

American Indian or Alaskan NativeAsianBlack or African AmericanHispanicNative Hawaiian/Other Pacific IslanderWhiteOther
Ethnicity*

Hispanic or LatinoNative Hawaiian/Other Pacific IslanderNot Hispanic or Latino
Preferred Language

EnglishSpanishOther
Collecting race, ethnicity, and language data helps promote equity through enhanced patient-provider communication and the provision of evidence-based quality care. Achieving the goals of quality care requires monitoring to ensure that all populations receive patient-centered, safe, effective, timely, efficient, and equitable care. Insurance Information

Insurance Information (Write "None") if no insurance*

	Company	Subscriber Name	Membership Number
Primary Vision Insurance
Second Vision Insurance
Primary Medical Insurance
Second Medical Insurance

I authorize the release of any medical information necessary to process any claims(s) to my insurance company, social security administration, or any of the above named insurances. I request all payments under the insurance program be made to me or to the provider for services and materials furnished to me during the effective period of this authorization. This assignment will remain in effect until revoked by me in writing.

I understand that I am financially responsible for all charges incurred and in the event that insurance payments are sent directly to me, I will remit payment to this office. If my insurance does not pay all bills submitted, I acknowledge that these bills are my responsibility and will guarantee payment. I further agree to pay any reasonable cost, including attorney and collection agency cost, in the event my account becomes delinquent.
Print Name (patient or parent/guardian)
Patient Signature (or parent/guardian)*

Clear
Date

MonthDayYear
Date
Windward Mall 46-056 Kamehameha Highway Kaneohe, HI 96744
Kailua Professional Building 30 Aulike Street, Suite 102 Kailua, HI 96734
Patient HEALTH History

Dr. Gerald Matsuda Dr. Stuart Machida Dr. Kari Chang-Moses Dr. Shelley Tasaka Dr. Jenny Nguyen
Name*
Reason for Visit:*

Check Up (No Difficulty, Seeing Clearly And Comfortably)Seeing or Eye Problem (Please Explain)Please Explain
How Long Ago Was Your Last Complete Eye Exam?
Dilated

YesNo
Who Was Your Last Eye Doctor?
Who Is Your Primary Care Physician?*
Do you Wear Glasses

YesNo
How Old Are Your Present Glasses?
Have You Ever Worn Contact Lenses?

YesNo
Do You Currently Wear Contact Lenses?

YesNoSometimesExplain
State Contact Lens Type*
Please include Brand, Base Curve (B.C.), Diameter (Diam.), Power
If No, Are You Interested In Wearing Contact Lenses?

YesNoMaybe
Are You Currently Taking Any Drugs Or Medications?*

YesNoIf Yes, Please list
Are You Currently Allergic To Any Drugs Or Medications?*

YesNoIf Yes, Please list
Have You Ever Had Any Eye Disease, Eye Injury, Or Eye Surgery?

YesNoIf Yes, please describe
Do You Currently Smoke*

YesNo
Have You Ever Smoked Before?

YesNo
Do You Drink Alcohol?*

YesNo
Do You Use Recreational Drugs?*

YesNo
Height*
Weight*

Do You Have Any Of The Following Problems/Conditions (Please List):*

	Yes	No	Please List
Allergy (Hay Fever, Atopy, Etc.)
Cardiovascular (High Blood Pressure, Cholesterol, Heat Problems Etc.)
Constitutional (Fever, Weight Loss/Gain, Fatigue, Etc.)
Endocrine (Diabetes, Hormone, Thyroid, Etc.)
Gastrointestinal (Hernia, Ulcers, Acid Reflux, Etc.)
Genitourinary (Bladder Infection, Kidney Stones, Prostate, Etc.)
Head (Ears, Nose, Mouth, Throat) (Hearing Loss, Cough, Congestion, Dry Mouth, Etc.)
Hematologic/Lymphatic (Anemia, Blood Disorder, Bleeding Problems, Etc.)
Integumentary (Skin, Rashes, Acne, Eczema, Etc.)
Musculoskeletal (Arthritis, Joint, Osteoporosis, Etc.)
Neurological (Multiple Sclerosis, Headaches, Migraines, Etc.)
Psychiatric (Anxiety, Depression, ADHD, Bi-Polar, Etc.)
Respiratory (Asthma, Emphysema, Bronchitis, Etc.)
Currently Pregnant/Nursing

Do You Have Any Family History of: (Please List Family Member)

	List Family Member
Amblyopia
Blindness
Cataracts
Eye Surgery
Glaucoma
Macular Degeneration
Other Eye Problems
Diabetes
High Blood Pressure
High Cholesterol
Cancer
Other Medical Conditions

I ACKNOWLEDGE THAT I RECEIVED A COPY OF WINDWARD VISION CENTER’S NOTICE OF PRIVACY PRACTICES.
Signature*

Clear
Please sign.
Date

MonthDayYear
Date
Phone Number

Area CodePhone Number
46-056 Kamehameha Highway., Kaneohe, HI 96744, Ph. (808) 235-6641

30 Aulike Street, Suite 102, Kailua, HI 96734, (808) 262-8107
Should be Empty:

Windward VISION Center

Patient HEALTH History