Patient Information Form

Welcome to Our Office!

Please fill out the following information so we can become better familiar with any issues you may have and respond with the necessary treatment.

Personal Information

Patient's First Name Middle Initial Last Name

Email Address

How did you hear about our office?

Ocular History

Please check any of the following that you currently have or have had in the past:
Burning Eyes	Itching Eyes	Watery Eyes	Dryness
Eye Strain	Reading Difficulty	Glare	Headaches
Floaters or Spots in Vision	Redness	Soreness	Flashes of Light
Double Vision	Eye Injury	Eye Surgery

Please check any of the following conditions you or any member of your immediate family have or have had in the past:
Glaucoma	Macular Degeneration	Lazy Eye
Cataracts	Retinal Tear/Detachment	Blindness
Other Family Issues:

Do you...
Work at a computer for long periods?	Yes	No
Have more than one pair of glasses?	Yes	No
Want information on thinner, lighter lenses?	Yes	No
Wear bifocals?	Yes	No
Spend time outdoors?	Yes	No
Are you currently wearing contact lenses?	Yes	No
Brand (if known)

Medical History

Please check any of the following that you have or have had in the past:
High Blood Pressure	Diabetes	Stroke	Heart Disease
High Cholesterol	Thyroid Disease	Arthritis	Multiple Sclerosis
Seizures	Cancer (type:)	Respiratory Disease	Sinus/Allergy
Blood/Lymph Disorder	Kidney Disease	Genitourinary STDs	Lupus
Other Issues:

Do you regularly use tobacco?	Yes	No
Are you allergic to any medications? (If so, please list)
Please list any medications you take regularly (Rx, OTC, vitamins, etc.)

Please note that your personal information will be used solely for the purposes of providing quality treatment in our office. Email addresses and personal data is not shared or sold to other parties.

Thank you for using EyeCare Associates.

Insurance

We are pleased to accept several different types of insurance, including VSP, Blue Cross/Blue Shield, Midlands Choice, Medicare, Mutual of Omaha, Tricare and Medicaid. If you do not see your insurance listed, please check with our staff.