Patient Intake Form 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 ClubKapolei Wal-MartPearl City Sam's ClubPatient InformationName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Suffix Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone*Daytime Phone NumberCell Phone NumberMay we contact you via text messaging? Yes No We contact our patients via a third party service to remind and confirm appointments. Email AddressPreferred method of communication*Home PhoneText MessagingE-mailPersonal InformationGender*FemaleMaleDate of Birth* Date Format: MM slash DD slash YYYY Last 4 Social Security NumberMarital StatusDivorcedLegally SeparatedMarriedSingleWidowedOtherEmployment StatusEmployed Full-TimeEmployed Part-TimeNot EmployedOn Active Military DutyRetiredSelf-EmployedStudent Full-TimeStudent Part-TimeOtherEmployerOccupationHow were you referred to our office?Friend or FamilyFamily DoctorOphthalmologistInsurance CompanyNewspaperTelevisionRadioReceived MailingInternetOther OptometristOtherEmergency Contact Name Phone Number Do you have vision or medical insurance?*YesNoPrimary InsuranceYou will be required to present insurance cards at that time of your appointment.Insurance Company NameInsurance TypeMedical and VisionMedical OnlyVision OnlyIdentification NumberPlan NameGroup NumberIs the insurance under yourself?YesNoSponsor's Information Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Middle Last Suffix Date of Birth Last 4 SSN Relationship to SponsorDependantSpouseSecondary InsuranceDo you have secondary insurance?YesNoInsurance Company NameInsurance TypeMedical and VisionMedical OnlyVision OnlyIdentification NumberPlan NameGroup NumberIs the secondary insurance under yourself?YesNoSecondary Insurance: Sponsor Information Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Middle Last Suffix Date of Birth Last 4 SSN Relationship to Secondary Insuarance SponsorDependantSpouseReason For VisitType of Examination*Routine Vision ExaminationContact Lens ExaminationContact Lens Fitting/EvaluationMedical/Office VisitVision TherapyChief 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?Right EyeLeft EyeBoth EyesHow long have you noticed the issue?Please notate any associated symptoms: Headaches Glare/Light Sensitivity Tired Eyes Burning Dryness Watery Eyes Eye Pain and/or Soreness Foreign Body Sensation Infection of Eye or Lid Itching Mucous Discharge Drooping eyelid(s) Redness Sandy or Gritty Feeling Blurred Vision at Distance Blurred Vision at Near Haloes Double Vision Floaters or Spots Flashes of Light Fluctuating Vision Loss of Vision Are you using anything to alleviate the symptoms?Do you see any flashes of light?*YesNoHow long have you been experiencing the flashes of light?*Do you see any floaters?*YesNoHow long have you been experiencing the floaters?*Do you have any pain in your eyes?*YesNoOcular HistoryDate of last eye exam Date Format: MM slash DD slash YYYY Name of eye doctor First Name Last Name Were you diagnosed with any eye disease/conditions?*YesNoPlease select the disease/condition:GlaucomaCataractMacular DegenerationStrabismus/Eye TurnAmblyopiaOtherTo multi-select, hold the Ctrl button and select conditions.Have you ever had any eye or eyelid surgery or injury?*YesNoPlease describe the surgery/injury:Do you currently use any eye drops?*YesNoPlease list ALL the drops:Are you allergic to any medicated eye drops?*YesNoPlease list ALL the eye drops you are allergic to:Have you had your eyes dilated in the past?YesNoAside from sensitivity to light, have you ever had any complications with eye dilation? If so, please describe:GlassesDo you currently use glasses?*NoYesDo you feel that your current glasses need an improvement?NoYes, improvement on distance visionYes, improvement on near visionHow old is your current pair of glasses?Contact LensDo you currently wear contact lenses?*YesNoAre you satisfied with your current contact lens brand?YesNoAre you interested in being fitted with contact lenses?YesNoWhat type of contact lenses would you be most interested in?Soft Contact Lenses: Daily DisposibleSoft Contact Lenses: 2 Week Contact LensesSoft Contact Lenses: Monthly Contact LensesSoft Contact Lenses: Color Contact LensesSoft Contact Lenses: Multifocal/Monovision LensesRidged Gas Permeable Contact LensesWhat type of contact lenses would you be most interested in?Soft Contact Lenses: Daily DisposibleSoft Contact Lenses: 2 Week Contact LensesSoft Contact Lenses: Monthly Contact LensesSoft Contact Lenses: Color Contact LensesSoft Contact Lenses: Multifocal/Monovision LensesRidged Gas Permeable Contact LensesWhat 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 HistoryDo you drink alcohol?NoYes, 1 per weekYes, 1 per dayYes, 2 or 3 per dayYes, 4 or more per dayDo you use tobacco products?NoYes, 1/2 a pack per dayYes, 1 pack per dayYes, more than 1 pack per dayYes, otherDo you use illegal drugs?NoYesDo you currently drive?NoYesIs your driver's license going to expire within the next 6 months? If so, do you need a DMV certificate?YesNoMedical HistoryDate of last medical exam Date Format: MM slash DD slash YYYY Name of primary care doctor First Name Last Name The following section pertains to your CURRENT medical status:Are you pregnant or Nursing?NoYes, PregnantYes, NursingDo you CURRENTLY have any health conditions you are being monitored for?*YesNoAllergiesDrug AllergiesPet DanderDustPollenFood AllergiesOtherTo multi-select, hold the Ctrl button and select conditions.CardiovascularHypertensionBorderline HypertensionElevated CholesterolHeart AttackStrokeArrhythmiaArteriosclerosisCardiovascular DiseaseCoagulation DisorderCongestive Heart DiseaseEndocarditisHeart MurmurHeart PalpitationsMitral Valve ProlapseTo multi-select, hold the Ctrl button and select conditions.ConstitutionalAppetite (excess)Appetite (loss)AnemiaBlackoutsCar sicknessChillsColdsConstipationCoughingCrampsDisorientationDizzinessFaintingFatigueFeverGrowth (excess)NauseaNight SweatsNosebleedsSleep (irregularity)SweatingThirst (excess)Urination (excess)VomitingWeaknessWeight gainWeight lossTo multi-select, hold the Ctrl button and select conditions.EndocrineCholestrol, elevatedCrohn's DiseaseDiabetes InsipidusDiabetes MellitusDiabetes Steroid InducedDiabetic SuspectGoutHyperlipoproteinemiaHyperthyroidismHypoglycemiaPituitary DisorderRenal DiseaseThyroid DisorderTo multi-select, hold the Ctrl button and select conditions.GastrointestinalAcid-Reflux SyndromeAlcoholismAnorexiaCancer: ColonCancer: LiverCirrhosisColitisDiarrheaDiverticulosisDyspepsiaGall BladderGall StonesGardner's SyndromeGastritisGastroenteritisGasteroesophageal RefluxGastrointestinal DisorderHepatitisHepatic DiseaseHiatus HerniaInflammatory BowelIntestinal ObstructionJaudincePancretitisUlcer: DuodenalUlcer: PepticUlcer: StomachWhipple's DiseaseTo multi-select, hold the Ctrl button and select conditions.GastrointestinalMenopauseSexually Transmitted IllnessAmenorrheaBladder InfectionPregnancy: EctopicImpotenceKidney StonesOvarian CystsOvarian TumorPelvic Inflammatory DiseaseProstate DisorderProstate CancerSyphillisUterine CancerTo multi-select, hold the Ctrl button and select conditions.Hematologic/LymphaticAnemiaBreast CancerLeukemiaCavernous Sinus ThrombosisCoagulation DisorderHematologic DisorderHodgkin's DiseaseLymphatic CancerPernicious AnemiaPolycythemiaSickle Cell DiseaseTemporal ArteritisThalassemiaVaricose VeinsTo multi-select, hold the Ctrl button and select conditions.IntegumentaryAcneAcne RosaceaOcular RosaceaAtopic DermatitisPsoriasisContact DermatitisDermatitisLupusAlbinismCictricial PemphigoidBasal Cell Nevus SyndromeDry SkinErythema MultiformeErythema NodosumHemangiomaHypertrichosisImpetigoPemphigusPhotosensitivityPolyarteritis NodosaPruritusRaynaud's DiseaseSarcoid LesionSclerodermaSunburnUrticariaVitiligoWartsXerodermaTo multi-select, hold the Ctrl button and select conditions.MusculoskeletalAnkylosing SpondylitisArthritisArthritis: RheumatoidMyasthenia GravisOsteoporosisDown's SyndromeMarfan SyndromeMusclar DystrophyPaget's DiseasePolymyalgia RheumaticaSacroiliitisScoliosisSkeletal DisorderTo multi-select, hold the Ctrl button and select conditions.NeurologicalBell's PalsyEpilepsyHeadacheHeadache (Cluster)Headache (Migraine)Brain TumorMultiple SclerosisCerebral PalsyParkinson's DiseaseDyslexiaBrain DamageEncephalitisHorner's SyndromeHysteriaMalingeringMuscular DystrophyMyasthenia GravisNeuralgiaNeurofibromotosisNystagmusOlfactory DisorderOphthalmoplegiaSeizure DisorderSpinal Cord InjurySturge-Weber SyndromeTrigeminal NeuralgiaTuberous SclerosisVertigoVon Hippel-Lindau DiseaseTo multi-select, hold the Ctrl button and select conditions.PsychiatricAttention DisorderAutismAnxiety DisorderBi-Polar DisorderAlcoholismAlzheimer's DiseaseDementiaDepressionAnorexiaBrain Damage (Trauma)BulimiaDelusionsDrug Dependency (Current)Drug Dependency (Past)IllusionsInsomniaLearning DisabilityMemory Loss (Short-Term)Mood DisorderOrientation DisorderPersonality DisorderPsychiatric DisorderSchizophreniaSuicidal IdeationTo multi-select, hold the Ctrl button and select conditions.Have you ever had any hospital surgeries?*YesNoPlease describe the hospital surgeries:Do you currently take any medications?*YesNoPlease list ALL medications you are currently taking:Are you allergic to any medications?*YesNoPlease list ALL medications you are allergic to:Family HistoryThis applies to your IMMEDIATE family members (mother/father/siblings):Was anyone in your immediate family diagnosed with any eye disease/condition?*YesNoUnknownPlease list the eye disease/condition:GlaucomaCataractMacular DegenerationStrabismus/Eye TurnAmblyopiaTo multi-select, hold the Ctrl button and select conditions.Was anyone in your immediate family diagnosed with any systemic condition?*YesNoUnknownPlease list the systemic condition:HypertensionDiabetesMigrainesRheumatoid ArthritisAutismAsperger SyndromeTo multi-select, hold the Ctrl button and select conditions.AdditionalDo you have any additional concerns? Please list here:Privacy PolicyHealth Information Protection* I have read and agree to the Privacy Policy EmailThis field is for validation purposes and should be left unchanged.
