New Patient Form
Kingfisher Family Eyecare
Name
*
First Name
Last Name
Today's date
*
-
Month
-
Day
Year
Date
Date of birth
*
-
Month
-
Day
Year
Date
Date of last eye exam
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reason for today's visit
*
yearly check, blurry vision, etc.
Do you wear glasses?
*
Yes
No
Sometimes
How old is your present pair of lenses & frames?
Do you wear contact lenses?
Yes
No
What kind do you wear?
Rigid
Soft
Extended Wear
Dailies
Other
Are your contacts comfortable?
Yes
No
Are you interested in contact lenses?
Yes
No
Primary Care Physician (PCP)
*
Are you nursing?
*
Yes
No
Are you pregnant?
*
Yes
No
Do you currently have any problems in the following areas? If "YES" please provide information.
*
Rows
Yes
No
Explanation.
EYES
Glaucoma
Cataracts
Macular Degeneration
Retinal Disease
General/Constitutional (Fever, weight loss, etc.)
Ear, Nose, Throat (sinus, ear infection, dry mouth, etc.)
Heart and Blood (Heart failure, vessels, high blood pressure etc.)
Lung (asthma, emphysema etc.)
Gastrointestinal (Stomach ulcers, intestinal disease, Crohn’s, etc.)
Genital, kidney, bladder
Muscles, bones, joints (arthritis, etc.)
Skin (acne, warts, skin cancer, etc.)
Neurological (Stroke, multiple sclerosis, etc.)
Psychiatric (anxiety, depression, insomnia, ect.)
Endocrine (diabetes, thyroid, etc.)
Blood/lymph (cholesterolemia, anemia)
Allergic/immunologic (hay fever, lupus, Sjogren, etc.)
Family History
Any family eye disease? If “YES” please list: M = Mother; F =Father; S=Siblings; GP = Grandparents
*
Rows
Yes
No
Relationship
Macular Degeneration
Cataract
Glaucoma
Cancer
Diabetes
Heart disease or high blood pressure
Thyroid disease
Other
List any medications you currently take (prescription and over the counter):
*
Do you have any allergies to any medications?
*
Yes
No
Please list the medication(s):
Occupation:
*
Do you drive?
*
Yes
No
Do you have visual difficulty when driving?
Yes
No
Do you drink alcohol?
*
Yes
No
How much per day?
Do you smoke?
*
Yes
No
How much per day?
Insurance Information
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