intake form2

1Patient Information

2Insured/Guardian Information

3Medical History

INSURED / GUARDIAN INFORMATION
Name
Title
First Name*

Middle Name

Last Name*

Address
Address Line1*

Address Line2

State*

City*

Zipcode*

Contact
Home Phone*

Work Phone

Cell Phone

Email*

Gender
*

Male

Female
Relationship To Patient:
*

Employment Status
*

Full Time

Part Time

Retired

Unemployed
Employer
*

Employer's Phone Number

Occupation
*

Insurance and Payment Policies
Examination fees and co-pays are due when services are rendered. A deposit is required when ordering materials and full payment is due when materials are dispensed. Insurance coverage is not a guarantee of payment and therefore you may be billed for professional fees that are not covered by your insurance.
Please read and sign below
My signature hereby allows Southland Eye Associates to file any insurance claims on my behalf and release any and all information to my insurance company.
Signature
*

Date
Date

MEDICAL HISTORY
To comply with medical record requirements, please complete the following information.
Primary Care Physician
Name

City

State

Phone

Pharmacy
Name

City

State

Phone

Did you take any medical exam?
*

Yes

No
Last Medical Exam
Name*

Date
DD slash MM slash YYYY

Did you take any eye exam?
*

Yes

No
Last Eye Exam
Name*

Date
DD slash MM slash YYYY

What is the reason for today's eye exam ? Please mark all that apply.
*
blur at distance
headache
flashes/spots
broken glasses
blur at near
glaucoma
tears/discharge
contact lenses
double vision
lazy eye
eye pain/discomfort
other
computer strain
red eyes
itching
Have you had an eye injury?
*

No

Yes
If yes,explain.*

Have you had an eye surgery?
*

No

Yes
If yes,explain.*

How old are your current glasses ?
Months
∣
Years
I don't wear glasses
How old is the pair of contacts that you are currently wearing ?
Months
|
Years
I don't wear contacts
What brand of contacts do you currently wear ?
*

Are you happy with your current contact lenses ?
*

No

Yes
Do you sleep in your contacts ?
*

No

Yes
If yes, how often?*

How often do you replace your contact lenses ?
*

Do you have, or have you ever been treated for ? Please mark all that apply.
*
blur at near
stomach problems
STD
breathing problems
hearing loss
high blood pressure
thyroid/glands
cancer
depression/anxiety
other
heart disease
arthritis/joint pain
HIV
sinus allergy
stroke
kidney/urinary
headache
skin condition
Do you take any medications ?
*

No

Yes
If yes, list.*

Do you have allergies ?
*

No

Yes
If yes, explain.*

Do you smoke?
*

No

Yes
How much?*

Do you drink alcohol ?
*

No

Yes
How much?*

Do you have a history of recreational drug use?
*

No

Yes
Does anyone of your family members have any of the following medical problems ? Please mark all that apply.
*
diabetes
sickle cell disease
crossed eyes
high blood pressure
retinal disease
blindness
heart disease
glaucoma
other
arthritis
macular degeneration

Southlandeye Patient Medical Details Form

Are you here with whom?

Name

Address

Contact

Gender

Marital Status

Birthdate

Employment Status

Employer

Employer's Phone No

Occupation

School/College Name

Race

Ethnicity

Communication Preferences

Name

Address

Contact

Gender

Relationship To Patient:

Employment Status

Employer

Employer's Phone Number

Occupation

Signature

Date

Primary Care Physician

Pharmacy

Did you take any medical exam?

Last Medical Exam

Did you take any eye exam?

Last Eye Exam

What is the reason for today's eye exam ? Please mark all that apply.

Have you had an eye injury?

Have you had an eye surgery?

How old are your current glasses ?

How old is the pair of contacts that you are currently wearing ?

What brand of contacts do you currently wear ?

Are you happy with your current contact lenses ?

Do you sleep in your contacts ?

How often do you replace your contact lenses ?

Do you have, or have you ever been treated for ? Please mark all that apply.

Do you take any medications ?

Do you have allergies ?

Do you smoke?

Do you drink alcohol ?

Do you have a history of recreational drug use?

Does anyone of your family members have any of the following medical problems ? Please mark all that apply.

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