Search for:

Follow Us:

Home
Services
Products
- emPower!
- Nordic Naturals
News
EyeCyclopedia
Shopping
Forms
Contact Us
About Us

Convenient Office Hours

Monday 8:00am to 5:00pm
Tuesday 10:00am to 7:00pm
Wednesday 9:00am to 1:00pm
Thursday 10:00am to 7:00pm
Friday By Appointment
Saturday By Appointment

24/7 Emergency Care Provided

Schedule An Appointment

Address & Phone Number

3027 English Rows Ave, Ste 209
Naperville, IL 60564

630.922.2661 Phone
630.470.6979 Fax

Se Habla Español

EyeGlass Guide 2.0

New Patient Medical Questionnaire

New Patient Medical Questionnaire

Please join us in the effort to reduce the unnecessary waste of paper by filling out these history forms online. Every time this online form is used, it reduces paper waste by approximately 8 to 10 sheets of paper. Also, please read and review the Online HIPAA Privacy Policy, available on our Forms page. You will be required to acknowledge that you have reviewed the HIPAA Privacy Policy before your information can be submitted on the last page of this questionnaire.

Thank you for your efforts.

Filling out the following form now will help make your visit more punctual and thorough. Required areas to be completed are annotated with a red asterisk *

Step 1 of 9

11%

Personal Information
Name*
PrefixFirstLastSuffix
Please provide us with your full name.
Date of Birth*

Please enter your date of birth
SS#: last four digits*
Please provide the last four digits of your Social Security Number
Marital Status*
- Single
- Married
- Divorced
- Widowed
- Separated
- Partner
Please indicate your marital status
Sex*
- Male
- Female
Please indicate your sex type.
Home Address*
Street AddressAddress Line 2CityStateZip Code
Please provide your home address
Email*
Enter EmailConfirm Email
We only utilize client email information for internal communications to patients. Your information is never shared.
Home Phone*
Please provide your home or cell phone number
Work Phone
Please provide your work phone
Cell Phone
Please provide your cell/mobile phone number
Texting
- Allowed
Would you like to receive text you reminders?
Additional Visit Related Information
How did you hear about our office?
Reason For Visit
Please check all that apply
*
- Annual Exam
- Medical Exam
- Emergency Visit
- Contact Lenses
- Glasses
- Physician Consult
- Infection or Injury
- Something In Eye
- LASIK Consult
- Other (please state below)
Other:

Employer / Student Information
Employment Information*
- Employed Full-Time
- Employed Part-Time
- Self-employed
- Retired
- Student - FullTime
- Student - Part Time
- Unemployed
Please indicate your employment or student status.
Employer / School Attending
Please provide your employer name or the name of the school that you are currently attending.
Occupation / Grade Attending
Please provide your occupation title or grade level

Insurance Information
Do you have:*
- Medical Insurance
- Vision Insurance
- Both Medical & Vision Insurance
- No Insurance
Please provide your insurance status for us.
Medical Insurance Information
Medical Insurance Company (if applicable)
Policy #
Group #
Medicare #
Vision Insurance Information
Vision Insurance Company (if applicable)
Policy#
Vision Group#
Policy Holder Information
Policy Holder Name
Policy Holder's Date Of Birth
Policy Holder SS# (last four)
Relationship to Patient*
Policy Holder's Employer
Policy Holder Section Notes:

Patient Eye History
Date of last eye exam
By Whom:
Have you ever experienced, been diagnosed, or treated for the following:
- Blur at Distance
- Blur at Near
- Blur on Computer
- Glare / Halos
- Double Vision
- Loss of Side Vision
- Flashes of Light
- Crossed/turned eye
- Floaters / Spots
- Redness
- Grittiness
- Itchy eyes
- Burning
- Tearing
- Sunlight Sensitivity
- Trouble Seeing at Night
- Color Blindness
- Dryness
- Eye Pain
- Iritis / Uveitis
- Cataracts
- Glaucoma
- Macular Degeneration
- Amblyopia / Lazy Eye
- Corneal Abrasion
- Headaches
- Retinal Problems
- Eye Injury
- Eye Infection
- Other (explain below)
Other:
Do you currently wear:*
- Glasses
- Contact Lenses
- Both
- Neither

General Health
Your Primary Care Physician:
Phone
Date of Last Medical Exam:
Height*
Weight*
Have you ever experienced, been diagnosed, or treated for the following:
- Allergic / Immunologic
- Asthma
- Arthritis
- Cancer
- High Cholesterol
- Diabetes
- Cardiovascular
- High Blood Pressure
- Rosacea
- Muscles / Bones
- Blood / Lymph
- Prolonged Fever
- Mental
- Lupus
- Sinus Congestion
- Stroke
- Respiratory
- Arteriosclerosis
- Ear, Nose, Throat
- Neurological / Headaches
- Urinary
- Thyroid
- Herpes Infection
- Osteoporosis
- Skin Disorder
- Endocrine (glands)
- Gastrointestinal
Other:
Are you taking any medications? If yes, please enter medications and what you use them for*
- Yes
- No
Medication Information
Pharmacy Information
Please provide us with your pharmacy name, location, and phone number in the event that we need to contact them regard any prescriptions that need to be ordered on your behalf.
Pharmacy Name:
Pharmacy Location:
Pharmacy Phone Number:
Allergies
Please list any allergies that you may have
Medication Allergies:
Insect Bite Allergies:
Food Allergies:
Seasonal Allergies:*
- Yes
- No
Other Allergies:

Family Medical History
Is there a family medical history of any of the following? If so, please check the appropriate boxes and indicate in the Notes section of this page if it is maternal or paternal as well as the relationship you have.
Family Health Issues
- Blindness
- Cataracts
- Glaucoma
- Macular Degeneration
- Lazy Eye
- Retinal Problems
- Corneal Problems
- Heart Disease
- Diabetes
- High Blood Pressure
- Cancer
- Thyroid
- Other
Please make sure to indicate the relationship for each family health issue if it is maternal and/or paternal in the notes section below:
Notes / Other:

Social History
Please describe your history below
Tobacco Use:*
- Never
- Former Smoker
- Everyday Smoker
- Occasional Smoker
- Smokeless Tobacco
- Cigars
If former smoker, quit:
- Within Last Year
- 1-2 years ago
- 2-3 years ago
- 3-4 years ago
- 5+ years ago
- 10+ years ago
Alcohol Use*
- None
- Social Only
- 1-2 Drinks / Day
- >2 Drinks / Day
- Alcohol Dependance
Narcotic Use:
- None
- Recreational Use
- Chemical Dependance
Sexually Transmitted Disease:
- None
- Yes
- HIV+
Blood Transfusion
- None
- Yes
- HIV+

Hobbies and Recreational Activities
Please check all that apply
- Golf
- Fishing
- Camping
- Sewing
- Needlepoint
- Swimming
- Cooking
- Scuba Diving
- Gardening
- Piano
- Skiing
- Tennis
- Other Sports
- Movies
- Reading
- Other Activities

Government Requested Information
The following information is now requested to be gathered by the United States Government by all medical practices.
Preferred Language:*
- English
- Spanish
- Other
Race:*
Ethnicity*
Preferred Communication Methods:*
- Email
- Postal Mail
- Telephone
HIPAA Privacy Acknowledgement
I acknowledge I have read and understand the HIPAA Patient Privacy Form (opens in new window if clicked) which was provided to me on this website. By selecting the date and typing your name you are electronically signing that you have reviewed and understand our HIPAA policy:
HIPAA Acknowledgement Date:*
HIPAA Acknowledgement Typed Name*
FirstLast

Share this:
Share

Reddit
Print

Recent Posts

Glaucoma – The Silent Thief of Sight
Just a Reminder!

Home
Services
Forms
News
About Us
Contact

Copyright © 2011 - English Rows Eye Care - All rights reserved. Terms and Privacy Policy

Site Design by Saying It First

Sign in to your account

Account Login

Username

Password

Forgot your password?