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New Patient Form

New Patient Form

Name *

Email Address *

Address

Address Line 1

City

State

Zip Code

Home Phone

Cell Phone

Birthday *

Social Security # (Last 4 digits)

Employer/Occupation

Work Phone

Sex *

Male
Female

Do you live alone?

Yes
No

Do you operate a motor vehicle?

Yes
No

Do you smoke?

Yes
No

In Case of Emergency, Contact Person

Name *

Relationship

Home Phone

Cell Phone

Work Phone

How Did You Hear About Us?

Radio/Television/Other

WHAM
WPXY
WCMW
Facebook
Newspaper
Yellow pages
Twitter
robbinseye.com
Channel 8
Channel 10
Channel 13
R News

Name of Friend/Relative

Name of Referring Physician or Eye Doctor

Reason for Referral

Medical Health History

Primary Care Physician

Work Phone

Medical Insurance

Policy Number

Eye Doctor's Name

Date of last eye exam

How long have you worn glasses?

Has your prescription been changing regularly? (a change every 1-2 years)

Yes
No

Are you a Contact Lens Wearer?

Yes
No

Soft
Hard
Third Choice
Gas permeable
Extended Wear

Total years worn

Last worn when?

Have you ever worn contact lenses for monovision to help with near tasks?

Yes
No

Medications currently being taken and dosages: (list all including vitamins and over the counter medication)

Allergies

Foods

Yes
No

Foods *

Iodine

Yes
No

Iodine *

Latex

Yes
No

Latex *

Medications

Yes
No

Medications *

Seasonal/Pollens

Yes
No

Seasonal/Pollens *

Skin

Yes
No

Skin *

Anxiety/Nervousness

Yes
No

Arthritis

Yes
No

Asthma

Yes
No

Breathing Problems

Yes
No

Cancer

Yes
No

Type *

Chronic Bronchitis

Yes
No

Collagen Vascular Disease

Yes
No

Contact Lens Wear Problems

Yes
No

Depression

Yes
No

Diabetes

Yes
No

Chronic Dry eyes

Yes
No

Eczema/Psoriasis

Yes
No

Family History of Keratoconus

Yes
No

Fibromyalgia/Chronic Fatigue

Yes
No

Do you smoke?

Yes
No

Number of packs per day *

Heart Problems

Yes
No

Hepatitis

Yes
No

Herpes Zoster(shingles)

Yes
No

Herpes Simplex (cold sores)

Yes
No

High Blood Pressure

Yes
No

High Cholesterol

Yes
No

Lupus Erythematosis

Yes
No

Rheumatoid Arthritis

Yes
No

Sjogren’s Syndrome

Yes
No

Skin Problems

Yes
No

TB

Yes
No

Thyroid Disease

Yes
No

Menopausal/ Postmenopausal

Yes
No

Pregnant/ Nursing

Yes
No

Do you have pain in your eyes upon awakening in the morning?

Yes
No

Have you ever had abnormal or unusually slow healing from a skin wound or injury?

Yes
No

Have you ever had problems with fainting when receiving shots or when having blood drawn?

Yes
No

Have you had or are you considering cosmetic eyelid surgery?

Yes
No

When? *

Do you use artificial tears?

Yes
No

Name of brand and how often *

Any Previous Eye Injuries?

Yes
No

What type and when? *

Any Previous Eye Surgery?

Yes
No

What type of surgery (PRK, LASIK,Cataract ) and when? *

Have you or anyone in your family ever been diagnosed with or had: Cataracts, Corneal Transplants, Glaucoma or Unexplained Poor Vision?

Yes
No

Who *

Any additional eye or general health information that we should be aware of:

Release Of Information

I assign all medical/surgical benefits to Robbins Eye Associates for services performed by Robbins Eye Associates staff and authorize the release of information concerning my care to the health insurance agency. I understand and agree that, regardless of insurance status, I am ultimately responsible for the balances of my account for any professional services rendered. Furthermore, I understand that if my account is turned over for collection, I will be responsible for all fees and expenses incurred by any collection agency or attorney.

Date *

Signature *

(Patient/Guardian/Responsible Individual – must be 18 years or older to sign)

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