New Patient Intake Form
Personal Information
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
First Name
Middle Name
Last Name
Suffix
Nickname
Name you prefer to be called while in our office
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Sex
*
Male
Female
Social Security Number
Marital Status
Married
Single
Widowed
Divorced
Domestic Partnership
Work Status
Full-Time
Part-Time
Contract
Student
Unemployed
Employer/School
Occupation
Race
*
Asian
Black or African American
Native American
Native Hawaiian or Pacific Islander
White
Other
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Preferred Language
*
How did you first hear about St. Lucy's Vision Center?
If you heard about us through another patient, please include their name so we can send them a thank-you!
Contact Information
Home Phone Number
*
-
Area Code
Phone Number
Work Phone Number
-
Area Code
Phone Number
Cell Phone Number
*
-
Area Code
Phone Number
May we text your cell phone to allow you to quickly confirm or reschedule upcoming appointments?
*
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
Preferred Contact Method:
*
Telephone
Email
Postal
Guardian/Responsible Party Information
Is the patient a minor?
*
Yes
No
Guardian/Responsible Party Name
First Name
Last Name
Address is the same as patient:
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home phone is the same as patient:
Yes
No
Phone Number
-
Area Code
Phone Number
Relationship to patient
Emergency Contact
Name
*
First Name
Last Name
Relationship to Patient
*
Contact Phone Number
*
-
Area Code
Phone Number
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Privacy Policies and Consent Forms
Notice of Privacy Practices and HIPAA Agreements
I acknowledge that I received a copy of William H. Stephen, O.D. Notice of Privacy Practices.
Patient Authorization to Disclose Protected Health Information
HIPAA policy prevents our office sharing your protected heath information (PHI) with anyone other than yourself without your consent. If you would like someone other than yourself to have access to your health record, please include their name below.
Office Policies
I have read and understand the office policies of St. Lucy's Vision Center.
St. Lucy's Vision Center Finance Agreement
I authorize this office to release any information necessary to expedite insurance claims. I authorize use of signatures on this form for insurance claim submissions. I authorize payment directly to my doctor. I understand that I am responsible for all charges, regardless of insurance coverage. All accounts past 60 days are subject to 1 ½ % finance charge – annual rate 18%.
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Insurance Information
Vision Insurance
Though often provided in conjunction with medical health insurance plans, vision plans generally are managed through a separate insurance company (e.g Vision Service Plan, VSP, Eyemed). These plans provide discounts and benefits towards routine eye exams, glasses and contact lenses, but not for medical eye issues such as disease, infections or injuries. For most patients, the vision insurance company managing these benefits is not the same as their health insurance company.
Do you have vision insurance?
*
Yes
No
Insurance Company Name
Policy Holder's Name
First Name
Last Name
Policy Holder's Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Insurance Policy/ID Number
Insurance Group Number
Medical Insurance
Medical insurance can be used within our practice for the treatment and management of eye diseases, infections, injuries and other non-routine services. We encourage all our patients to provide this information even if you are scheduled only for your routine eye exam. Having this information on file will allow us to manage, treat, or refer to other providers for medical issues should any arise during your visit.
Do you have medical insurance
*
Yes
No
Policy Holder's Name
First Name
Last Name
Policy Holder's Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Insurance Company Name
Insurance Policy/ID Number
Insurance Group Number
Is this an HMO plan?
Yes, this is an HMO plan
No, this is a PPO plan
Unsure
Secondary Medical Insurance
Do you have a secondary medical insurance plan?
*
Yes
No
Policy Holder's Name
First Name
Last Name
Policy Holder's Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Insurance Company Name
Insurance Group Number
Insurance Policy/ID Number
Is this an HMO plan?
Yes, this is an HMO plan
No, this is a PPO plan
Unsure
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Medical History
Systemic Medical History
Primary Care Doctor
*
Doctor's Phone Number
-
Area Code
Phone Number
Medications
Please list any medications you are currently taking, including prescription medications, over-the-counter-medications, and supplements. Please list the reason for taking the medication, if applicable.
Medical History: Allergies
Do you have any allergies to medications?
*
Yes
No
List medication allergies
Do you have any non-medication allergies?
*
Yes
No
List allergens
Medical History: Cardiovascular
Please select any of the following that you have been diagnosed with or treated for:
Angina
Arrhythmia
Arteriosclerosis
Cardiovascular Disease
Coagulation Disorder
Congestive Heart Failure
Elevated Cholesterol
Endocarditis
Heart Murmur
Heart Palpitations
Hypertension
Mitral Valve Prolapse
Myocardial Infarction
Stroke
Other
Please include any additional information you would like to doctor to have regarding your cardiovascular health history:
Medical History: Endocrine
Please select any of the following that you have been diagnosed with or treated for:
Cholesterol Elevated
Crohn’s Disease
Diabetes Insipidus
Diabetes Mellitus
Diabetes w/ Retinopathy
Diabetic Suspect
Gout
Hyperthyroidism
Hypoglycemia
Pituitary Disorder
Renal Disease
Thyroid Disorder
Other
Last Blood Glucose Level Reading
Is your blood-sugar level controlled?
Yes
No
Please include any additional information you would like to doctor to have regarding your endocrine health history:
Medical History: Gastrointestinal
Please select any of the following that you have been diagnosed with or treated for:
Acid-Reflux Syndrome
Cancer: Lung, Colon, Liver
Cirrhosis
Colitis
Diverticulosis
Gall Bladder Disorder
Gall Stones
Gardner’s Syndrome
Gastroenteritis
Gastroesophageal Reflux (GERD)
Gastrointestinal Disorder
Hepatic Disease
Inflammatory Bowel
Pancreatitis
Ulcer: Duodenal, Peptic, Stomach
Whipple’s Disease
Other
Please include any additional information you would like to doctor to have regarding your gastrointestinal health history:
Medical History: Genitourinary
Please select any of the following that you have been diagnosed with or treated for:
Amenorrhea
Bladder Infections
Pregnancy
Kidney Stones
Menopause
Ovarian Cyst
Ovarian Tumor
Pelvic Inflammatory Disease
Prostate Disorder
Prostate Cancer
Uterine Cancer
Other
Please include any additional information you would like to doctor to have regarding your genitourinary health history:
Medical History: Head
Please select any of the following that you have been diagnosed with or treated for:
Chronic Cough
Dental Disorder
Dry Mouth
Ear Infection
Encephalitis
Headaches-Migraines/Cluster
Hearing Loss: Full or Impaired
Meniere’s Syndrome
Sinusitis
Other
Please include any additional information you would like to doctor to have regarding your head health history:
Medical History: Hematologic/Lymphatic
Please select any of the following that you have been diagnosed with or treated for:
Anemia
Breast Carcinoma
Coagulation Disorder
Hematologic Disorder
Hogkin’s Disease
Leukemia
Lymphatic Cancer
Polycythemia
Sickle Cell Disease
Temporal Arteritis
Thalassemia
Other
Please include any additional information you would like to doctor to have regarding your hematologic/lymphatic health history:
Medical History: Immunologic
Please select any of the following that you have been diagnosed with or treated for:
AIDS
Diphtheria
Herpes Zoster
Histoplasmosis
HIV Positive
Lupus
Lyme Disease
Newcastle Disease
Reye’s Syndrome
Rheumatic Fever
Rubella
Sarcoidosis
Sjogren’s Syndrome
Staphylococcus Infection
Tuberculosis
Other
Please include any additional information you would like to doctor to have regarding your immunologic health history:
Medical History: Integumentary (Skin)
Please select any of the following that you have been diagnosed with or treated for:
Acne
Acne Rosacea
Atopic Dermatitis
Contact Dermatitis
Dermatitis
Dry Skin
Eczema
Psoriasis
Raynaud’s Disease
Scleroderma
Other
Please include any additional information you would like to doctor to have regarding your integumentary health history:
Medical History: Musculoskeletal
Please select any of the following that you have been diagnosed with or treated for:
Ankylosing Spondylitis
Arthritis
Arthritis: Rheumatoid
Down’s Syndrome
Marfan’s Syndrome
Muscular Dystrophy
Myasthenia Gravis
Osteoporosis
Paget’s Disease
Scoliosis
Skeletal Disorder
Other
Please include any additional information you would like to doctor to have regarding your musculoskeletal health history:
Medical History: Neurological
Please select any of the following that you have been diagnosed with or treated for:
Bell’s Palsy
Brain Damage
Brain Tumor
Cerebral Palsy
Dyslexia
Encephalitis
Epilepsy
Headaches
Muscular Dystrophy
Multiple Sclerosis
Neuralgia
Neurofibromatosis
Parkinson’s Disease
Seizure Disorder
Spinal Cord Injury
Sturge-Weber Syndrome
Trigeminal Neuralgia
Tuberous Sclerosis
Von Hippel-Lindau Disease
Other
Please include any additional information you would like to doctor to have regarding your neurological health history:
Medical History: Respiratory
Please select any of the following that you have been diagnosed with or treated for:
Asthma
Bronchitis
COPD
Cystic Fibrosis
Emphysema
Lung Disease or Cancer
Pneumonia
Pulmonary Insufficiency
Respiratory Dysfunction
Sarcoidosis
Tuberculosis
Other
Please include any additional information you would like to doctor to have regarding your respiratory health history:
Medical History: Psychiatric
Please select any of the following that you have been diagnosed with or treated for:
ADD
Alzheimer’s Disease
Anxiety Disorder
Autism
Bipolar Disorder
Brain Damage
Dementia
Depression
Learning Disability
Mood Disorder
Orientation Disorder
Personality Disorder
Psychiatric Disorder
Schizophrenia
Other
Please include any additional information you would like to doctor to have regarding your psychiatric health history:
Surgical History
Have you every had any major surgeries, injuries or hospitalizations
*
Yes
No
List major surgeries, injuries or hospitalizations and the dates they occurred:
Is there any additional information you would like the doctor to have concerning your medical history?
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Ocular History
Ocular Medical History
How long has it been since your last eye exam?
Never
1-6 months ago
7-11 months ago
1 year ago
2-3 years ago
3-4 years ago
5+ years ago
10+ years ago
Do you wear glasses?
Yes
No
What type(s) of glasses do you wear?
Single vision
Bifocal
Trifocal
Progressives
Computer glasses
Prescription sunglasses
Non-prescription sunglasses
Other
Do you wear contact lenses, or have you in the past?
Yes
No
What type of contact lenses do you use?
Soft Lenses
Rigid Lenses (RGP)
Ortho-keratology lenses (Ortho-K, CRT, Overnight Sight)
Previous wearer, no longer wearing lenses regularly
Other
Please select any of the following that you have been diagnosed with or treated for:
Amblyopia
Asteroid Hyalosis
Blepharitis
Cataracts
Color Deficiency
Corneal Abrasion
Diabetic Retinopathy
Dry Eye Syndrome
Eye Injury/Trauma
Glaucoma
Keratoconus
Macular Degeneration
Macular Hole
Nystagmus
Pinguecula
Retinal Detachment/Hole
Retinitis Pigmentosa
Other
Please select any of the following surgeries/procedures you have had:
Blepharoplasty
Cataract surgery
Corneal Transplant
Enucleation
Eye muscle surgery
Glaucoma surgery
LASIK
PRK
RK
Retinal Detachment Repair
YAG laser capsulotomy
Other
Are you currently using any eye drops regularly?
Yes
No
List Eye Drops Used:
Is there any additional information you would like the doctor to have concerning your ocular history?
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Family and Social History
Family History
Please indicate any family history (parents, grandparents, siblings, children) for the following:
Blindness
Cataract
Crossed Eyes
Glaucoma
Macular Degeneration
Retinal Detachment/Disease
Other Eye Conditions
Diabetes
High Blood Pressure
Elevated Cholesterol
Arthritis
Cancer
Heart Disease
Other
Blindness: Please list relationship to patient
Cataract: Please list relationship to patient
Crossed Eyes: Please list relationship to patient
Glaucoma: Please list relationship to patient
Macular Degeneration: Please list relationship to patient
Retinal Detachment/Disease: Please list relationship to patient
Other Eye Conditions: Please list relationship to patient
Diabetes: Please list relationship to patient
High Blood Pressure: Please list relationship to patient
Elevated Cholesterol: Please list relationship to patient
Arthritis: Please list relationship to patient
Cancer: Please list relationship to patient
Heart disease: Please list relationship to patient
Other: Please list relationship to patient
Social History
Do you use tobacco products?
Yes
No
Former Smoker/Tobacco User
Do you drink alcohol
No
Yes, Social use only
Yes, 1-2 drinks daily
Above average use
Alcohol dependence
Do you use illegal drugs?
Yes
No
Have you ever had a blood transfusion?
Yes
No
Have you ever been exposed to or infected with:
Gonorrhea
Hepatitis
HIV
Syphilis
None
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