Established Patient Information

1
Patient Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Primary Phone Number* This field is required.
Area Code
Phone Number
4
Has your address changed since your last visit?* This field is required.
YESNO
5
Please provide your new 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
6
Preferred Pharmacy (Name and Cross Streets)* This field is required.If you do not have a preferred pharmacy enter "None"
7
Emergency Contact Name & Phone Number
8
Medical Insurance Information* This field is required.Please select how you would like to update your insurance information:
My insurance information has not changed since my last visit.
Upload a picture of my insurance card
Manually enter my insurance information
I do not have medical insurance.
9
Please upload a picture of the FRONT of your insurance card.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
10
Please upload a picture of the BACK of your insurance card.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
11
Please provide your medical insurance information:
Medical Insurance Company Name
Member ID Number
12
Insurance Authorization* This field is required.
I authorize the staff & doctors of Eyecare Center of DuPage to bill my insurance company/Medicare as my agent on my behalf.
I assign payment of my insurance/Medicare benefits directly to Eyecare Center of DuPage on my behalf.
I understand I am personally financially responsible to the Eyecare Center of DuPage for payment of this account regardless of any insurance coverage I may have. The filing of any claims to my insurance does not remove me from my financial responsibility.
13
Please provide the name of your primary care provider.
14
Do you see an endocrinologist?
YESNO
15
Please provide the name of your endocrinologist.
16
Do you see a rheumatologist?
YESNO
17
Please provide the name of your rheumatologist.
18
Please indicate any eye surgeries you have had.* This field is required.Check all that apply.
Cataract Surgery
LASIK/RK/PRK
Glaucoma Surgery
Retinal Surgery
Other
None
19
Please enter the eye surgery not previously listed.
20
Eye Health History* This field is required.Check all that apply.
Dry Eyes
Cataracts
Myopia
Glaucoma
Macular Degeneration
Retinal Tear/Detachment
Injury
Other
None
21
Please enter eye health history item not previously listed.
22
Please indicate any systemic diseases you have ever been told you have:* This field is required.
Diabetes (Including Pre-Diabetes)
High Blood Pressure (Hypertension)
High Cholesterol
Autoimmune Conditions
Cancer
Other
None
23
Please enter systemic disease not previously listed.
24
Please provide most recent A1C:
25
Current Medications* This field is required.Please select how you would like to update your current medications:
Upload a List
Enter Manually
I am not on any medications.
26
Please upload a list of your current medications.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
27
Please list your current medications.
Huge
Large
Normal
Small
Ok
Ok
28
Do you have any drug allergies? * This field is required.
YESNO
29
Please list any known drug allergies.* This field is required.
30
How do you currently correct your vision?* This field is required.
I don't need vision correction.
Glasses
Contacts
Orthokeratology
31
What types of glasses do you currently use?* This field is required.
Bifocal Glasses
Progressive Glasses
Single Vision - Reading Only
Single Vision - Distance Only
Prescription Sunglasses
Computer Glasses
32
Please rate your glasses on the following:* This field is required.Use the blue sliders to select your desired rating.
Far Vision Correction
Intermediate/Computer Vision Correction
Near Vision Correction
Physical Comfort
Not Satisfied
Somewhat Satisfied
Satisfied
Row 0, Column 0Row 0, Column 1Row 0, Column 2
Not Satisfied
Somewhat Satisfied
Satisfied
Row 1, Column 0Row 1, Column 1Row 1, Column 2
Not Satisfied
Somewhat Satisfied
Satisfied
Row 2, Column 0Row 2, Column 1Row 2, Column 2
Not Satisfied
Somewhat Satisfied
Satisfied
Row 3, Column 0Row 3, Column 1Row 3, Column 2
Far Vision Correction
Intermediate/Computer Vision Correction
Near Vision Correction
Physical Comfort
Not Satisfied
Somewhat Satisfied
Satisfied
Row 0, Column 0Row 0, Column 1Row 0, Column 2
Not Satisfied
Somewhat Satisfied
Satisfied
Row 1, Column 0Row 1, Column 1Row 1, Column 2
Not Satisfied
Somewhat Satisfied
Satisfied
Row 2, Column 0Row 2, Column 1Row 2, Column 2
Not Satisfied
Somewhat Satisfied
Satisfied
Row 3, Column 0Row 3, Column 1Row 3, Column 2
33
What is one thing you would change about your current glasses?
Huge
Large
Normal
Small
Ok
Ok
34
Regarding your Orthokeratology treatment, please rate the following:* This field is required.Use the blue sliders to select your desired rating. 1 = Poor / 10 = Excellent
Daytime Vision
Retainer Comfort
1
2
3
4
5
6
7
8
9
10
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4Row 0, Column 5Row 0, Column 6Row 0, Column 7Row 0, Column 8Row 0, Column 9
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9
10
Row 1, Column 0Row 1, Column 1Row 1, Column 2Row 1, Column 3Row 1, Column 4Row 1, Column 5Row 1, Column 6Row 1, Column 7Row 1, Column 8Row 1, Column 9
Daytime Vision
Retainer Comfort
1
2
3
4
5
6
7
8
9
10
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4Row 0, Column 5Row 0, Column 6Row 0, Column 7Row 0, Column 8Row 0, Column 9
1
2
3
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8
9
10
Row 1, Column 0Row 1, Column 1Row 1, Column 2Row 1, Column 3Row 1, Column 4Row 1, Column 5Row 1, Column 6Row 1, Column 7Row 1, Column 8Row 1, Column 9
35
When was the last time you skipped a night of retainer wear?* This field is required.
I wear my retainers every night.
Last night
1 - 2 Weeks Ago
2 - 4 Weeks Ago
36
Which disinfecting solution do you use?* This field is required.
Clear Care Triple Action
Clear Care Plus w/Hydraglyde
Boston Advance Cleaner
Generic Brand Hydrogen Peroxide
Other
37
Please list the brand/name of the disinfecting solution you use.* This field is required.
38
Which drops do you use with your retainers?* This field is required.
Blink Contacts
Refresh Plus
0.9% Sodium Chloride Solution
Other
39
Please list the brand/name of the drops you use with your retainers.* This field is required.
40
Is there anything else about your Ortho-K treatment that you would like to discuss with the doctor?
Huge
Large
Normal
Small
Ok
Ok
41
Regarding your contact lens wear, please rate the following:* This field is required.Use the blue sliders to select your desired rating. 1 = Poor / 10 = Excellent
Vision w/Contacts
Contact Lens Comfort
1
2
3
4
5
6
7
8
9
10
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4Row 0, Column 5Row 0, Column 6Row 0, Column 7Row 0, Column 8Row 0, Column 9
1
2
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7
8
9
10
Row 1, Column 0Row 1, Column 1Row 1, Column 2Row 1, Column 3Row 1, Column 4Row 1, Column 5Row 1, Column 6Row 1, Column 7Row 1, Column 8Row 1, Column 9
Vision w/Contacts
Contact Lens Comfort
1
2
3
4
5
6
7
8
9
10
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4Row 0, Column 5Row 0, Column 6Row 0, Column 7Row 0, Column 8Row 0, Column 9
1
2
3
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5
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8
9
10
Row 1, Column 0Row 1, Column 1Row 1, Column 2Row 1, Column 3Row 1, Column 4Row 1, Column 5Row 1, Column 6Row 1, Column 7Row 1, Column 8Row 1, Column 9
42
Which disinfecting/multipurpose solution do you use?* This field is required.
Clear Care Triple Action
Clear Care Plus w/Hydraglyde
Generic Brand Hydrogen Peroxide
Biotrue
Opti-Free Puremoist
Boston Adv. Cleaner & Cond.
None
Other
43
Please list the brand/name of the disinfecting/multipurpose solution you use.* This field is required.
44
How many times per day do you use lubricating drops with your contact lenses?* This field is required.
Never
Once
Twice
More than twice.
45
Which lubricating drops do you use with your contact lenses?* This field is required.
Blink Contacts
Refresh Plus
Oasis Tears Plus
Other
46
Please list the brand/name of the lubricating drops you use.* This field is required.
47
Is there anything else about your contact lenses that you would like to discuss with the doctor?
Huge
Large
Normal
Small
Ok
Ok
48
Additional reason for visit:
Orthokeratology / Corneal Reshaping
Myopia Management
Contact Lenses
Glasses
Diabetic Eye Exam
Dry Eye Evaluation and Management
49
Signature* This field is required.
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