New Patient Info (v0624)

1
Name* This field is required.
Full Legal Name (First, Middle, Last)
Preferred/Chosen Name
2
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Preferred Phone Number* This field is required.
Area Code
Phone Number
4
Secondary Phone Numberclick NEXT if none
Area Code
Phone Number
5
Email* This field is required.
example@example.com
6
I agree to limit information communicated via email, text, or voice message to the following (select all permissions):* This field is required.
Leave message with call back number ONLY
OK to message with detailed information
7
Date of Birth* This field is required.
Date
Year
Month
Day
8
Gender* This field is required.
Female
Male
Non-Binary
9
Race and Ethnicity* This field is required.Choose all that apply
White
Black/African American
Asian
Native American
Pacific Islander
Hispanic/Latino
Non-Hispanic/Latino
Other
10
Preferred Language* This field is required.
English
Other
11
Patient Status* This field is required.
Single
Married
Other
12
Employer* This field is required.
13
Occupation* This field is required.
14
How did you hear about us?
15
Name of Primary Medical Doctor/Practice* This field is required.
16
Name of preferred pharmacy and cross-streets* This field is required.ie "CVS Dobson and Germann"
17
Emergency Contact and/or Parent/Guardian Information* This field is required.
First Name
Last Name
18
Emergency Contact Phone Number* This field is required.
Area Code
Phone Number
19
Relationship to Patient
20
Do you authorize this office to discuss your medical care and account information with any person other than yourself?* This field is required.Select all that apply
Emergency contact listed above
Do not discuss my care with anyone
I authorize my information to be shared with the following
21
Name of additional authorized personClick Next if NA
First Name
Last Name
22
Phone number of authorized personClick Next if NA
Area Code
Phone Number
23
Relationship to patientClick Next if NA
24
Name of additional authorized personClick Next if NA
First Name
Last Name
25
Phone number of additional authorized personClick Next if NA
Area Code
Phone Number
26
Relationship to patientClick Next if NA
27
CONSENT, ASSIGNMENT, RELEASE and FINANCIAL POLICY* This field is required.
28
Signature* This field is required.I have read, understand, and agree to the Falcon Family Eye Care Consent, Assignment, Release, and Financial Policy
Clear
29
PRIVACY POLICY* This field is required.The Falcon Family Eye Care Notice of Privacy Practices is available for your review below. If you wish to receive a copy to take with you, please let the staff know, and we will provide you with a copy.
30
Signature* This field is required.I have read, understand, and agree to the Falcon Family Eye Care Privacy Policy
Clear
31
REFRACTION POLICY* This field is required.
32
Signature* This field is required.I have read, understand, and agree to the Falcon Family Eye Care Refraction Policy
Clear
33
DILATION POLICY* This field is required.
34
Signature* This field is required.I have read, understand, and agree to the Falcon Family Eye Care Dilation Policy
Clear
35
DIGITAL RETINAL WELLNESS ASSESSMENT* This field is required.
36
Signature* This field is required.I have read, understand, and agree to the Falcon Family Eye Care Dilation Policy
Clear
37
CONTACT LENS POLICY AND AGREEMENTAll patients interested in contact lens wear must sign
38
SignatureI have read, understand, and agree to abide by the terms and policies of the Falcon Family Eye Care Contact Lens Agreement as outlined above.
Clear
39
Are you currently experiencing any of the following ocular problems?* This field is required.
Blurred vision at distance
Blurred vision at near
Eyestrain/Tired eyes
Headache
Squinting
Glare/Halos/Stars around lights
Difficulties with night driving
Double vision
Eye pain or soreness
Foreign body sensation
Dry or sandy feeling
Redness
Burning or stinging
Itching
Watering or excess tearing
Discharge or crusting around eyes
Flashes of light
New or worsening floaters
Veil, curtain, or spiderweb in vision
Loss of vision
NO OCULAR OR VISION COMPLAINTS
Other
40
Where is the problem located? (select all that apply)* This field is required.
NO PROBLEMS
Right eye
Left eye
Both eyes
Eye lid
Eye ball
Front of eye
Behind/Back of eye
Other
41
When did the problem begin?select next if not applicable
42
What is the timing of the problem? (select all that apply)select next if not applicable
Constant
Intermittent
Worse in AM
Worse in PM
Worsens throughout day
Other
43
What is the severity of the problem?select next if not applicable
1
2
3
4
5
6
7
8
9
10
Mild
Severe
44
Context: Is the problem associated with any activity?select next if not applicable
45
Please describe the quality of the problem:select next if not applicable
Acute (recently began)
Chronic (longstanding)
Improved since initial presentation
Worsening since initial presentation
46
Does anything make the problem better or worse?select next if not applicable
47
Are there any other signs or symptoms associated with the problem?select next if not applicable
48
Do you currently wear any of the following?* This field is required.
Prescription glasses
Non-prescription readers
Contact lenses
Prescription sunglasses
Safety glasses
Computer/Reading/Work station-specific glasses
I do not currently wear glasses or contact lenses
49
Are you interested in contact lens wear or will you need to order contact lenses in the next 12 months?* This field is required.
Yes
No
50
Have you or an immediate family member been diagnosed with, treated for, or suspected of having any of the following ocular conditions?* This field is required.
None
Self
Mother
Father
Sibling
Child
Grandparent
Other relative
Glaucoma
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Cataract
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Row 1, Column 6
Row 1, Column 7
Macular Degeneration
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Row 2, Column 6
Row 2, Column 7
Keratoconus
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Row 3, Column 6
Row 3, Column 7
Dry Eye Syndrome
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Row 4, Column 6
Row 4, Column 7
Retinal Detachment
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 5, Column 5
Row 5, Column 6
Row 5, Column 7
Glaucoma
Cataract
Macular Degeneration
Keratoconus
Dry Eye Syndrome
Retinal Detachment
None
Row 0, Column 0
Self
Row 0, Column 1
Mother
Row 0, Column 2
Father
Row 0, Column 3
Sibling
Row 0, Column 4
Child
Row 0, Column 5
Grandparent
Row 0, Column 6
Other relative
Row 0, Column 7
None
Row 1, Column 0
Self
Row 1, Column 1
Mother
Row 1, Column 2
Father
Row 1, Column 3
Sibling
Row 1, Column 4
Child
Row 1, Column 5
Grandparent
Row 1, Column 6
Other relative
Row 1, Column 7
None
Row 2, Column 0
Self
Row 2, Column 1
Mother
Row 2, Column 2
Father
Row 2, Column 3
Sibling
Row 2, Column 4
Child
Row 2, Column 5
Grandparent
Row 2, Column 6
Other relative
Row 2, Column 7
None
Row 3, Column 0
Self
Row 3, Column 1
Mother
Row 3, Column 2
Father
Row 3, Column 3
Sibling
Row 3, Column 4
Child
Row 3, Column 5
Grandparent
Row 3, Column 6
Other relative
Row 3, Column 7
None
Row 4, Column 0
Self
Row 4, Column 1
Mother
Row 4, Column 2
Father
Row 4, Column 3
Sibling
Row 4, Column 4
Child
Row 4, Column 5
Grandparent
Row 4, Column 6
Other relative
Row 4, Column 7
None
Row 5, Column 0
Self
Row 5, Column 1
Mother
Row 5, Column 2
Father
Row 5, Column 3
Sibling
Row 5, Column 4
Child
Row 5, Column 5
Grandparent
Row 5, Column 6
Other relative
Row 5, Column 7
1 of 6
51
Have you undergone any of the following eye surgeries/procedures/injuries?* This field is required.
No previous eye injuries, procedures, or surgeries
Cosmetic Injections, Fillers, or Procedures around eyes
Cataract Surgery
LASIK
PRK
RK
Retinal Detachment Repair
Corneal Transplant
Significant Eye Injury
Strabismus/Eye Alignment Surgery
Other
52
Please provide eye, date, and circumstances of above surgeries/procedures/injuries.select next if not applicable
53
Have you or a family member, currently or in the past, been diagnosed with, treated for, or suspected of having any of the following conditions?* This field is required.
None
Self Currently
Self, Past
Parent
Grandparent
Child
Other relative
Insulin dependent Diabetes
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Non Insulin Dependent Diabetes
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Row 1, Column 6
High Blood Pressure
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Row 2, Column 6
High Cholesterol
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Row 3, Column 6
Heart/Artery Disease
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Row 4, Column 6
Thyroid Problems
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 5, Column 5
Row 5, Column 6
Parkinson's
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Row 6, Column 5
Row 6, Column 6
Alzheimer's or Dementia
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Row 7, Column 5
Row 7, Column 6
MS
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Row 8, Column 5
Row 8, Column 6
Cancer
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
Row 9, Column 5
Row 9, Column 6
Insulin dependent Diabetes
Non Insulin Dependent Diabetes
High Blood Pressure
High Cholesterol
Heart/Artery Disease
Thyroid Problems
Parkinson's
Alzheimer's or Dementia
MS
Cancer
None
Row 0, Column 0
Self Currently
Row 0, Column 1
Self, Past
Row 0, Column 2
Parent
Row 0, Column 3
Grandparent
Row 0, Column 4
Child
Row 0, Column 5
Other relative
Row 0, Column 6
None
Row 1, Column 0
Self Currently
Row 1, Column 1
Self, Past
Row 1, Column 2
Parent
Row 1, Column 3
Grandparent
Row 1, Column 4
Child
Row 1, Column 5
Other relative
Row 1, Column 6
None
Row 2, Column 0
Self Currently
Row 2, Column 1
Self, Past
Row 2, Column 2
Parent
Row 2, Column 3
Grandparent
Row 2, Column 4
Child
Row 2, Column 5
Other relative
Row 2, Column 6
None
Row 3, Column 0
Self Currently
Row 3, Column 1
Self, Past
Row 3, Column 2
Parent
Row 3, Column 3
Grandparent
Row 3, Column 4
Child
Row 3, Column 5
Other relative
Row 3, Column 6
None
Row 4, Column 0
Self Currently
Row 4, Column 1
Self, Past
Row 4, Column 2
Parent
Row 4, Column 3
Grandparent
Row 4, Column 4
Child
Row 4, Column 5
Other relative
Row 4, Column 6
None
Row 5, Column 0
Self Currently
Row 5, Column 1
Self, Past
Row 5, Column 2
Parent
Row 5, Column 3
Grandparent
Row 5, Column 4
Child
Row 5, Column 5
Other relative
Row 5, Column 6
None
Row 6, Column 0
Self Currently
Row 6, Column 1
Self, Past
Row 6, Column 2
Parent
Row 6, Column 3
Grandparent
Row 6, Column 4
Child
Row 6, Column 5
Other relative
Row 6, Column 6
None
Row 7, Column 0
Self Currently
Row 7, Column 1
Self, Past
Row 7, Column 2
Parent
Row 7, Column 3
Grandparent
Row 7, Column 4
Child
Row 7, Column 5
Other relative
Row 7, Column 6
None
Row 8, Column 0
Self Currently
Row 8, Column 1
Self, Past
Row 8, Column 2
Parent
Row 8, Column 3
Grandparent
Row 8, Column 4
Child
Row 8, Column 5
Other relative
Row 8, Column 6
None
Row 9, Column 0
Self Currently
Row 9, Column 1
Self, Past
Row 9, Column 2
Parent
Row 9, Column 3
Grandparent
Row 9, Column 4
Child
Row 9, Column 5
Other relative
Row 9, Column 6
1 of 10
54
Please describe any other systemic illness or potentially inherited disorder in your current, past, or family history. Also include information on type of cancer if applicable:select next if not applicable
55
Please describe any past major illness, injury, surgery, or hospitalization. Indicate none if applicable.* This field is required.
56
Please list any prescription medications, vitamins, supplements, or OTC medications you are currently taking. Indicate 'none' or 'see list' if applicable.* This field is required.If indicating 'see list', please bring list to the appointment.
57
Please list any allergies to medications. Indicate none if applicable. * This field is required.
58
Smoking Status. Select all that apply.* This field is required.
Current 1+pack/day
Current
Occasional smoker
Vape
Former smoker/vaper
Never smoker/vaper
59
Alcohol Consumption:* This field is required.
None
Social/Occasional
3-5/wk
Daily
60
Do you currently use recreational or street drugs?* This field is required.
Yes
No
I currently use medical marijuana
61
How many nights a week do you sleep in your lenses?select next if not applicable
62
How often do you throw away each pair of lenses?select next if not applicable
63
How old is the pair of lenses you are currently wearing?select next if not applicable
64
Please list brand and powers of current contact lenses if known.select next if not applicable
65
Are you currently experiencing any of the following symptoms or problems:* This field is required.
Allergic/Immunologic problems(seasonal allergies, hives, eczema, rash, lumps, etc)
Cardiovascular problems (chest pain, racing heart, skipping beats, paliptations, shortness of breath, etc)
Constitutional problems (fever, chills or night sweats, weight loss/gain, etc)
Endocrine problems (Diabetes, thyroid disease, heat or cold intolerance, frequent urination, increase or decrease in thirst or appetite, etc)
GI problems (heartburn/acid reflux/GERD, nausea, vomiting, stomach pain, diarrhea or constipation, etc)
Ear, Nose, Throat, or Mouth Problems (ringing in ears or ear pain, hearing problems, ear infection, stuffy or runny nose, nosebleeds, sneezing or seasonal rhinitis, sore throat or hoarseness, problems with teeth or gums, mouth sores, etc)
Blood or Lymphatic problems (bruising, bleeding, anemia, leukemia, etc)
Skin problems (moles changing in shape, color or size, non healing skin lesions, dry or itchy skin, skin color changes, rashes, bumps or sores, etc)
Musculoskeletal problems (muscle or joint pain, stiffness, back pain, joint swelling, etc)
Neurological problems (Dizziness, fainting, seizures, weakness, numbness or tingling in extremities, unsteadiness or recent falls, migraine, etc)
Psychiatric problems (Nervousness or anxiety, depression, memory loss, stress, mood changes, etc)
Respiratory problems (new or newly productive cough, trouble catching breath, wheezing, asthma, bronchitis or emphysema, exposure to tuberculosis, etc)
I AM EXPERIENCING NO CURRENT HEALTH PROBLEMS
Other
66
Signature* This field is required.I certify that I have answered the above questions to the best of my ability.
Clear
Should be Empty: