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 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*
MM slash DD slash YYYY
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*
- Routine Vision Examination
- Contact Lens Examination
- Contact Lens Fitting/Evaluation
- Medical/Office Visit
- Vision Therapy
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:
- 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?*
- 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
MM slash DD slash YYYY
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
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?
- No
- Yes, Pregnant
- Yes, Nursing
Have you received any of the COVID-19 vacinations?*
- No
- Yes
- Prefer not to answer
Which vaccine have you received?
- Moderna
- Pfizer
- Johnson and Johnson
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
Do you have any additional concerns? Please list here:
Privacy Policy
Health Information Protection*
- I have read and agree to the Privacy Policy
Phone
This field is for validation purposes and should be left unchanged.

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Patient Information

Personal Information

Primary Insurance

Secondary Insurance

Reason For Visit

Ocular History

Social History

Medical History

Family History

Additional

Privacy Policy