Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.

This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Please select your location:*

Keeaumoku Sam's Club
Kapolei Wal-Mart
Pearl City Sam's Club

Patient Information

Name*

Prefix First Middle Last Suffix

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone*

Daytime Phone Number

Cell Phone Number

May we contact you via text messaging?

Yes
No

We contact our patients via a third party service to remind and confirm appointments.

Email Address

Preferred method of communication*

Personal Information

Gender*

Female
Male

Date of Birth*

Last 4 Social Security Number

Marital Status

Employment Status

Employer

Occupation

How were you referred to our office?

Emergency Contact

Name Phone Number

Do you have vision or medical insurance?*

Yes
No

Primary Insurance

You will be required to present insurance cards at that time of your appointment.

Insurance Company Name

Insurance Type

Medical and Vision
Medical Only
Vision Only

Identification Number

Plan Name

Group Number

Is the insurance under yourself?

Yes
No

Sponsor's Information

Prefix First Middle Last Suffix

Date of Birth Last 4 SSN

Relationship to Sponsor

Secondary Insurance

Do you have secondary insurance?

Yes
No

Insurance Company Name

Insurance Type

Medical and Vision
Medical Only
Vision Only

Identification Number

Plan Name

Group Number

Is the secondary insurance under yourself?

Yes
No

Secondary Insurance: Sponsor Information

Prefix First Middle Last Suffix

Date of Birth Last 4 SSN

Relationship to Secondary Insuarance Sponsor

Reason For Visit

Type of Examination*

Chief Complaint*

Please detail your main vision or ocular health concern. Type "NA" if you are here for a routine exam and are not experiencing any difficulty.

Which eye is affected?

How long have you noticed the issue?

Please notate any associated symptoms:

Are you using anything to alleviate the symptoms?

Do you see any flashes of light?*

Yes
No

How long have you been experiencing the flashes of light?*

Do you see any floaters?*

Yes
No

How long have you been experiencing the floaters?*

Do you have any pain in your eyes?*

Yes
No

Ocular History

Date of last eye exam

Name of eye doctor

First Name Last Name

Were you diagnosed with any eye disease/conditions?*

Yes
No

Please select the disease/condition:

To multi-select, hold the Ctrl button and select conditions.

Have you ever had any eye or eyelid surgery or injury?*

Yes
No

Please describe the surgery/injury:

Do you currently use any eye drops?*

Yes
No

Please list ALL the drops:

Are you allergic to any medicated eye drops?*

Yes
No

Please list ALL the eye drops you are allergic to:

Have you had your eyes dilated in the past?

Yes
No

Aside from sensitivity to light, have you ever had any complications with eye dilation? If so, please describe:

Glasses

Do you currently use glasses?*

No
Yes

Do you feel that your current glasses need an improvement?

No
Yes, improvement on distance vision
Yes, improvement on near vision

How old is your current pair of glasses?

Contact Lens

Do you currently wear contact lenses?*

Yes
No

Are you satisfied with your current contact lens brand?

Yes
No

Are you interested in being fitted with contact lenses?

Yes
No

What type of contact lenses would you be most interested in?

Soft Contact Lenses: Daily Disposible
Soft Contact Lenses: 2 Week Contact Lenses
Soft Contact Lenses: Monthly Contact Lenses
Soft Contact Lenses: Color Contact Lenses
Soft Contact Lenses: Multifocal/Monovision Lenses
Ridged Gas Permeable Contact Lenses

What type of contact lenses would you be most interested in?

Soft Contact Lenses: Daily Disposible
Soft Contact Lenses: 2 Week Contact Lenses
Soft Contact Lenses: Monthly Contact Lenses
Soft Contact Lenses: Color Contact Lenses
Soft Contact Lenses: Multifocal/Monovision Lenses
Ridged Gas Permeable Contact Lenses

What is your typical wearing schedule? In days per week:

Please enter a number from 0 to 7.

What brand of contact lenses do you wear?

How old are your current lenses?

How often do you replace or dispose your contact lenses?

What brand of solution do you soak your lenses in?

What is your typical wearing schedule? In hours per day:

Please enter a number from 0 to 24.

Social History

Do you drink alcohol?

Do you use tobacco products?

Do you use illegal drugs?

Do you currently drive?

Is your driver's license going to expire within the next 6 months? If so, do you need a DMV certificate?

Medical History

Date of last medical exam

Name of primary care doctor

First Name Last Name

The following section pertains to your CURRENT medical status:

Do you CURRENTLY have any health conditions you are being monitored for?*

Yes
No

Allergies

To multi-select, hold the Ctrl button and select conditions.

Cardiovascular

To multi-select, hold the Ctrl button and select conditions.

Constitutional

To multi-select, hold the Ctrl button and select conditions.

Endocrine

To multi-select, hold the Ctrl button and select conditions.

Gastrointestinal

To multi-select, hold the Ctrl button and select conditions.

Gastrointestinal

To multi-select, hold the Ctrl button and select conditions.

Hematologic/Lymphatic

To multi-select, hold the Ctrl button and select conditions.

Integumentary

To multi-select, hold the Ctrl button and select conditions.

Musculoskeletal

To multi-select, hold the Ctrl button and select conditions.

Neurological

To multi-select, hold the Ctrl button and select conditions.

Psychiatric

To multi-select, hold the Ctrl button and select conditions.

Have you ever had any hospital surgeries?*

Yes
No

Please describe the hospital surgeries:

Do you currently take any medications?*

Yes
No

Please list ALL medications you are currently taking:

Are you allergic to any medications?*

Yes
No

Please list ALL medications you are allergic to:

Family History

This applies to your IMMEDIATE family members (mother/father/siblings):

Was anyone in your immediate family diagnosed with any eye disease/condition?*

Yes
No
Unknown

Please list the eye disease/condition:

To multi-select, hold the Ctrl button and select conditions.

Was anyone in your immediate family diagnosed with any systemic condition?*

Yes
No
Unknown

Please list the systemic condition:

To multi-select, hold the Ctrl button and select conditions.

Additional

Picture ID*

Drop files here or

Please upload the FRONT and BACK of your picture ID. If you do not feel comfortable uploading your ID, please take a picture of yourself. For patients under the age of 18, parents/legal guardians please upload your ID/picture. If you upload a photo of yourself, you will be requested to present a government issued ID at the time of your appointment.

Insurance Card(s)

Drop files here or

Please upload the FRONT and BACK of your insurance cards. Please note that some insurances do not provide a card.

Do you have any additional concerns? Please list here:

Privacy Policy

Health Information Protection*

I have read and agree to the Privacy Policy

Comments

This field is for validation purposes and should be left unchanged.

Appetite (excess)
Appetite (loss)
Anemia
Blackouts
Car sickness
Chills
Colds
Constipation
Coughing
Cramps
Disorientation
Dizziness
Fainting
Fatigue
Fever
Growth (excess)
Nausea
Night Sweats
Nosebleeds
Sleep (irregularity)
Sweating
Thirst (excess)
Urination (excess)
Vomiting
Weakness
Weight gain
Weight loss

Acid-Reflux Syndrome
Alcoholism
Anorexia
Cancer: Colon
Cancer: Liver
Cirrhosis
Colitis
Diarrhea
Diverticulosis
Dyspepsia
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Gall Stones
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Gastrointestinal Disorder
Hepatitis
Hepatic Disease
Hiatus Hernia
Inflammatory Bowel
Intestinal Obstruction
Jaudince
Pancretitis
Ulcer: Duodenal
Ulcer: Peptic
Ulcer: Stomach
Whipple's Disease

Acne
Acne Rosacea
Ocular Rosacea
Atopic Dermatitis
Psoriasis
Contact Dermatitis
Dermatitis
Lupus
Albinism
Cictricial Pemphigoid
Basal Cell Nevus Syndrome
Dry Skin
Erythema Multiforme
Erythema Nodosum
Hemangioma
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Pemphigus
Photosensitivity
Polyarteritis Nodosa
Pruritus
Raynaud's Disease
Sarcoid Lesion
Scleroderma
Sunburn
Urticaria
Vitiligo
Warts
Xeroderma

Bell's Palsy
Epilepsy
Headache
Headache (Cluster)
Headache (Migraine)
Brain Tumor
Multiple Sclerosis
Cerebral Palsy
Parkinson's Disease
Dyslexia
Brain Damage
Encephalitis
Horner's Syndrome
Hysteria
Malingering
Muscular Dystrophy
Myasthenia Gravis
Neuralgia
Neurofibromotosis
Nystagmus
Olfactory Disorder
Ophthalmoplegia
Seizure Disorder
Spinal Cord Injury
Sturge-Weber Syndrome
Trigeminal Neuralgia
Tuberous Sclerosis
Vertigo
Von Hippel-Lindau Disease

Attention Disorder
Autism
Anxiety Disorder
Bi-Polar Disorder
Alcoholism
Alzheimer's Disease
Dementia
Depression
Anorexia
Brain Damage (Trauma)
Bulimia
Delusions
Drug Dependency (Current)
Drug Dependency (Past)
Illusions
Insomnia
Learning Disability
Memory Loss (Short-Term)
Mood Disorder
Orientation Disorder
Personality Disorder
Psychiatric Disorder
Schizophrenia
Suicidal Ideation