Optique New Patient Form

Name

First NameLast Name
Salutation: *
Preferred Name
What is your Marital Status? *

SingleMarriedDivorcedWidowed
Sex: *
Race*
Ethnicity*
Address:*
City: *
State: *
Zip: *
Date of Birth: *
Age: *
Home Phone #: *
Work Phone #: *
Cell Phone #: *
Email Address: *
Preferred Contact Method: *
Employer: *
Occupation: *
Social Security #:
How were you referred to our office? *
If you were referred by an individual, would you like to tell us who it was?
Please tell us about any hobbies, sports, or other activities in which you participate. This information can help us to determine the best care for your eyes. *
Insurance Information
HEALTH Insurance Company Name: *
Employer:
ID Number:
Group Number:
Name of Policy Holder:
Insured's Date of Birth:
Insured's Social Security Number:
Patient's Relationship to Insured:
VISION Insurance Company Name: *
Employer:
ID Number or Group Number:
Name of Policy Holder:
Insured's Date of Birth:
Insured's Social Security Number:
Patient's Relationship to Insured:
Do you wear glasses

NeverFull-TimePart-TimeDistance OnlyNear Work Only
What type of glasses do you own?

Single VisionProgressiveBifocalsTrifocalsSafety GlassesSports GlassesBackup GlassesReadersOtherNone
Do you use a computer?

YesNo
If so, how many hours per day?
How many inches are your eyes from your monitor?
Contact Lens History

Type a question

Yes

Do you currently wear contact lenses?

If you currently wear contact lenses, do your backup eyeglasses have your correct prescription?

Are you having any problems with your current contacts?

Answer the questions below ONLY IF you currently wear contact lenses:
What type or brand of contacts do you wear?
How old are your current lenses?
How often do you replace or dispose of your contact lenses?
What brand of solution do your lenses soak in overnight?
On average, how many hours per day do you wear your contacts?
On average, how many days per week do you wear your contacts?
Would you like to be evaluated for refractive laser surgery?

YesNo
Medical History
Date of Last Eye Exam: *
Where did you get your last eye exam? *
Date of Last Physical Exam:
Name of Primary Care Physician:

Do you suffer from:

Yes

Headaches?

Glare/Light Sensitivity?

Tired Eyes?

Amblyopia (lazy eye)?

Burning?

Dryness?

Epiphora (excess tearing)?

Eye Pain or Soreness?

Foreign Body Sensation?

Infection of Eye or Lid?

Itching?

Mucous Discharge?

Night Driving Difficulties?

Ptosis (drooping eyelid)?

Redness?

Sandy or Gritty Feeling?

Strabismus (crossed eyes)?

Blurred Distance Vision?

Blurred Near Vision?

Distorted Vision (haloes)?

Double Vision?

Floaters or Spots?

Fluctuating Vision?

Loss of Vision?

Loss of Side Vision?

Many diseases of the body have grave eye health consequences. While the questions below may seem unrelated to your eye health, it is crucial to your care that we ask them.
Have you ever been treated for any MEDICAL CONDITIONS?(e.g., diabetes, high blood pressure, arthritis) *

YesNo
If YES, please explain:
Have you ever had any EYE DISEASE? (e.g., glaucoma, cataracts, wandering or "lazy" eye, retinal detachment) *

YesNo
If YES, please explain:
Have you ever had any SURGERY for your eyes or any other condition?

YesNo
If YES, please explain:
Do you take any MEDICATIONS?

YesNo
If YES, please list:
Do you have any food or drug ALLERGIES?

YesNo
If YES, please explain:
Are you currently pregnant or nursing? *

Type a question

Yes

Chronic fever / unexpected weight loss or gain / fatigue?

Ear/Nose/Throat problems (e.g., hearing loss, sinus problems, sore throat?)

Heart problems (e.g., chest pain, irregular heartbeat, swelling of feet, cold hands/feet?

Respiratory problems (e.g., shortness of breath, wheezing, coughing)?

Gastrointestinal problems (e.g., heartburn, abdominal pain, diarrhea, vomiting)?

Genitourinary problems (e.g., painful urination, blood in urine, sex organ problems)?

Musculoskeletal problems (e.g., muscle aches, joint pain, swollen joints)?

Skin problems (e.g., rashes, excessive dryness, growths or lumps)?

Neurological problems (e.g., numbness, weakness, headaches, blackouts)?

Psychiatric problems (e.g., depression, anxiety)?

Endocrine problems (e.g., frequent urination, thirst, feeling hot or cold much of the time)?

Blood/Lymph problems (e.g., bruising, weakness, unusual paleness, swollen glands)

Immune problems (e.g., frequent infections; allergic reactions to foods, dust, pollens)?

If you answered YES to any of the previous questions, please explain:
Family/Social History
Do any MEDICAL or EYE DISEASES run in your family (blood relatives only)?

YesNo
If YES, please explain:
Do you consume alcohol? *

NeverOccasionally1 drink per day2-3 drinks per day4+ drinks per day
Do you smoke?

NeverOccasionally1/2 pack per day1 pack per day1+ pack per day
Insurance Disclaimer

We will gladly assist you in filing insurance for which we are a provider but we cannot assume responsibility for your insurance policies. Verification of benefits and authorizations received from your insurance company are not a guarantee of payment. The amount you will pay today is your estimated portion. I understand that Optique Vision Center will bill me for any items and/or services denied by my insurance company. I understand that I am personally and financially responsible for these charges and hereby authorize the provider to release any information required to process my insurance claim. I also authorize my insurance benefits to be paid directly to the doctor.
Patient’s Signature (parent/guardian if patient is a minor) *
Date *
Notice of Privacy Practices

Click to view our Notice of Privacy Practices.I acknowledge that I have had a chance to view and print out a copy of the Optique Vision Center Notice of Privacy Practices.
Patient’s Signature (parent/guardian if patient is a minor) *
Date *
Sign, Print, Submit

If this is being completed for a minor, please list a name and phone # for an adult we may contact for further information.
Patient’s Signature (parent/guardian if patient is a minor) *
Date *
Phone #
Should be Empty:

Insurance Information

Contact Lens History

Medical History

Family/Social History

Insurance Disclaimer

Notice of Privacy Practices

Sign, Print, Submit