Name: Eye Q Optometrist
Address: 1098 Wilmot Rd, Scarsdale, NY, 10583, US
Telephone: 914-472-5932
Price range: $000 - $300

New Patient Registration & Medical History Form (Scarsdale)

Please complete the information below and submit the form online. This form contains confidential information and is delivered to your doctor through a secure Internet connection.
Patient Information
Name*
First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Number*
Please provide a telephone number, with area code, so we can contact you.
Cell Phone
Work Phone
Email Address
Please provide your email address.
Employer
Occupation
Date of Birth*
Date Format: MM slash DD slash YYYY
Social Security Number (last 4 digits only!)
Race/Ethnicity
Preferred Language
Sex
- Female
- Male
Who may we thank for referring you to our office?
Primary Insurance
Please bring all insurance cards with you to your appointment.
Insurance Company Name
Insurance Company Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insured's Name
First Last
Identification Number
Group Number
Insured's Date of Birth
Date Format: MM slash DD slash YYYY
Patient's Relation to Insured
Secondary Insurance
Do you have secondary insurance?
- Yes
- No
If you have coverage through another plan/organization, please fill in the details below.
Insurance Company Name
Insurance Company Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insured's Name
First Last
Identification Number
Group Number
Insured's Date of Birth
Date Format: MM slash DD slash YYYY
Pharmacy info
Enter in local and mail order pharmacy details
Date of Last Medical Exam
Name of Medical Doctor
Doctor's Phone Number
Name of Eye Doctor
Date of Last Eye Exam
Current Height
Current Weight
Spouse or Guardian (If Applicable)
Medical History
Do you have any allergies to medications?
- No
- Yes
If Yes, list medication(s) and reaction below:
List any medications you take including oral contraceptives, aspirin, OTC medicines, etc.:
Include Name of Medication, Dosage, Frequency Taken
List all major injuries, surgeries and/or hospitalizations you have had:
Including any Eye surgeries
Check any of the following that you have had:
- Crossed Eyes
- Lazy Eye
- Drooping Eyelid
- Prominent Eyes
- Cataracts
- Glaucoma
- Iritis/Uveitis
- Macular Degeneration
- Retinal Disease of Detachment
- Eye Infections
- Eye Injury
- Corneal Problems
- Eye Surgery or Laser
- Other Eye Disorders
If Other Eye Disorders, please explain:
Are you pregnant or nursing?
- No
- Yes
Do you wear glasses?
- No
- Yes
If Yes, how old is your present pair of lenses?
Do you wear overnight orthokeratology molds?
- No
- Yes
AOK
If Yes, how old is your present pair of molds?
Do you wear contact lenses?
- No
- Yes
If Yes, how old is your present pair of lenses?
Type of Contact Lenses:
- Rigid
- Soft
- Extended Wear
- Scleral
- Other
Are they comfortable?
- No
- Yes
Family History
Note any family history (parents, grandparents, siblings, children, living or deceased) for the following conditions. When listing relationship, if a grandparent, please specify maternal or paternal.
Disease/Condition
- Blindness
- Cataract
- Crossed Eyes
- Glaucoma
- Macular Degeneration
- Retinal Detachment or Disease
- Arthritis
- Cancer
- Diabetes
- Heart Disease
- High Blood Pressure
- Kidney Disease
- Lupus
- Thyroid Disease
- Other
If Other, please explain:
If Yes to any of the above, please explain:
Please indicate which family member has the condition: Mother, Father, Child, Maternal Grandmother or Grandfather, Paternal Grandmother or Grandfather, Distant Relative
Social History
This information is kept strictly confidential. You may discuss this portion directly with the doctor if you prefer. Please check the box below of you prefer to discuss with the doctor instead.
I prefer to discuss my Social History information directly with my doctor.
- Yes
Do you drive?
- No
- Yes
If Yes, do you have visual difficulty when driving?
- No
- Yes
If Yes, please describe:
Do you use tobacco products?
- No
- Yes
If Yes, list type/amount/how long:
Do you drink alcohol?
- No
- Yes
If Yes, list type/amount/how long:
Do you use illegal drugs?
- No
- Yes
If Yes, list type/amount/how long:
Have you ever been exposed to or infected with:
- COVID-19
- Gonorrhea
- Hepatitis
- HIV
- Syphillis
REVIEW OF SYSTEMS
Do you currently or have you ever had any problems in the following areas?
Constitutional
Fever, Weight Loss/Gain
- No
- Yes
Integumentary (Skin)
- No
- Yes
Neurological
Headaches
- No
- Yes
Migraines
- No
- Yes
Seizures
- No
- Yes
Eyes
Loss of Vision
- No
- Yes
Blurred Vision
- No
- Yes
Distorted Vision/Halos
- No
- Yes
Loss of Side Vision
- No
- Yes
Double Vision
- No
- Yes
Dryness
- No
- Yes
Mucous Discharge
- No
- Yes
Redness
- No
- Yes
Sandy or Gritty Feeling
- No
- Yes
Itching
- No
- Yes
Burning
- No
- Yes
Foreign Body Sensation
- No
- Yes
Excess Tearing/Watering
- No
- Yes
Glare/Light Sensitivity
- No
- Yes
Eye Pain or Soreness
- No
- Yes
Chronic Infection, Eye or Lid
- No
- Yes
Styes or Chalazion
- No
- Yes
Flashes/Floaters in Vision
- No
- Yes
Tired Eyes
- No
- Yes
Endocrine
Thyroid/Other Glands
- No
- Yes
Elevated Cholesterol
- No
- Yes
Cancer
- No
- Yes
Ears, Nose, Mouth, Throat
Sinus Congestion
- No
- Yes
Runny Nose
- No
- Yes
Post-Nasal Drip
- No
- Yes
Chronic Cough
- No
- Yes
Dry Thoat/Mouth
- No
- Yes
Allergies/Hay Fever
- No
- Yes
Respiratory
Asthma
- No
- Yes
Chronic Bronchitis
- No
- Yes
Emphysema
- No
- Yes
Vascular/Cardiovascular
Diabetes
- No
- Yes
Heart Pain
- No
- Yes
High Blood Pressure
- No
- Yes
Vascular Disease
- No
- Yes
Gastrointestinal
Diarrhea
- No
- Yes
Constipation
- No
- Yes
Genitourinary
Genitals/Kidney/Bladder
- No
- Yes
Bones/Joints/Muscles
Rheumatoid Arthritis
- No
- Yes
Muscle Pain
- No
- Yes
Joint Pain
- No
- Yes
Lymphatic/Hematologic
Anemia
- No
- Yes
Bleeding Problems
- No
- Yes
Allergic/Immunologic
Allergic/Immunologic
- No
- Yes
Psychiatric
Psychiatric
- No
- Yes
If you answered Yes to any of the above or have a condition not listed, please explain and list medications:
Privacy Policy
read here our HIPAA policy
Health Information Protection*
- I have read and agree to the Privacy Policy
Signature*
Date*
Date Format: MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

New Patient Registration & Medical History Form (Scarsdale)

Patient Information

Primary Insurance

Secondary Insurance

Pharmacy info

Medical History

Family History

Social History

REVIEW OF SYSTEMS

Constitutional

Neurological

Eyes

Endocrine

Ears, Nose, Mouth, Throat

Respiratory

Vascular/Cardiovascular

Gastrointestinal

Genitourinary

Bones/Joints/Muscles

Lymphatic/Hematologic

Allergic/Immunologic

Psychiatric

Privacy Policy

Eye Q Optometrist

Eye Q Optometrist