Drs. Wilck, Schwartz and Novak O.D. - Patient Information Form
Welcome to our office!
Today's Date
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Month
-
Day
Year
Date
Name
*
Mr.
Mrs./Ms.
Prefix
First Name
Last Name
Street Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mail Address (if Different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
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Month
-
Day
Year
Date
Home Phone
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Area Code
Phone Number
Cell Phone
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Area Code
Phone Number
Email
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example@example.com
Emergency Contact Information
Name
First Name
Last Name
Mail Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship to Patient
Phone
-
Area Code
Phone Number
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Insurance Information
Please allow receptionist to photocopy your insurance ID Cards.
IF SOMEONE OTHER THAN PATIENT IS THE POLICY HOLDER, PLEASE INCLUDE DATE OF BIRTH FOR CLAIMS
Primary Insurance
Plan Name
Policy Holder's Name
First Name
Last Name
Policy Holder's Social Security #
Policy Holder's Date of Birth
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Month
-
Day
Year
Date
Policy / ID#
Group#
Eff Date
Claims Address & Phone
Secondary Insurance
Plan Name
Policy Holder's Name
First Name
Last Name
Policy Holder's Social Security #
Policy Holder's Date of Birth
-
Month
-
Day
Year
Date
Policy / ID#
Group#
Eff Date
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Medical Information
Do you have any of these problems?
Cardiovascular
Gastrointestinal
Ears/Nose/Throat
Allergic/Immunologic
High Blood Pressure
Genitourinary
Endocrine (glands)
Integumentary (Skin)
Musculoskeletal
Seizures
High Cholesterol
Mental Illness
Blood/Lymph
Nervous System
Respiratory
Stroke
Explain if necessary
Please Answer All That Apply
Family Physician
Last Eye Exam
By Dr.
Are you diabetic?
Yes
No
Type
Date of Diagnosis
Headaches?
Seldom
Occasional
Often
AM
PM
What part of head hurts?
Medication Allergy?
Yes
No
What happens?
Other Allergies?
Yes
No
What happens?
Current medication
Have you had any operations?
Yes
No
What kind?
When?
Do you currently smoke or use tobacco products?
Yes
No
Have you ever smoked or used tobacco products?
Yes
No
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Family History
Macular degeneration
Yes
No
Relation
Retinal Detachment
Yes
No
Relation
Glaucoma
Yes
No
Relation
Heart Disease
Yes
No
Relation
Cataracts
Yes
No
Relation
Diabetes
Yes
No
Relation
Other Eye conditions
Yes
No
Relation
Cancer
Yes
No
Relation
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Personal Eye Information
Do you experience any of these problems with your eyes?
Burning
Yes
No
Aching
Yes
No
Glaucoma
Yes
No
Itching
Yes
No
Watering
Yes
No
Cataracts
Yes
No
Blurred Vision
Yes
No
Dry Eyes
Yes
No
Flashes
Yes
No
Hurt in Bright Light
Yes
No
Double/Ghost Images
Yes
No
Floaters
Yes
No
Any other problems?
Past Head/Eye Trauma/Surgery?
Yes
No
Date
Do you wear Glasses?
Yes
No
Do you wear Contacts?
Yes
No
Contact Lens Brand
Base Curve (B. C.)
Prescription Right Eye
Prescription Left Eye
Are you interested in wearing contact lenses?
Yes
No
Signature
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Name
*
First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Today's Date
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Month
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Year
Date
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