New Patient Information Form

Office Hours

Monday 10:00am to 5:300pm
Tuesday 10:00am to 6:30pm
Wednesday 8:00am to 2:30pm
Thursday 10:00am to 6:30pm
Friday 8:00am to 2:30pm
Saturday By Appointment Only

3027 English Rows Ave. Suite 209

Naperville, IL 60564

PHONE: 630.922.2661
EMAIL: contactus@englishrow...

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 *

"*" indicates required fields

Step 1 of 9

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Name*

First Last

Please provide us with your full name.

Date of Birth*

MM slash DD slash YYYY

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 Address Address Line 2 City State ZIP Code

Please provide your home address

Email*

Enter Email Confirm 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

Cell Phone

Please provide your cell/mobile phone number

Work Phone

Please provide your work phone

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)

Type of Insurance Policy

PPO

HMO

Other

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

MM slash DD slash YYYY

Policy Holder SS# (last four)

Relationship to Patient*

Policy Holder's Employer

Policy Holder Section Notes:

Patient Eye History

Date of last eye exam

MM slash DD slash YYYY

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

Contact Lense Brand*

What type of contact lenses do you wear?*

Soft Contacts

Gas Perm

Hard Contacts

Other

Right Eye Prescription*

Left Eye Prescription*

General Health

Your Primary Care Physician:

Phone

Date of Last Medical Exam:

MM slash DD slash YYYY

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

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

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

Meaningful Use

Meaningful Use is a government program to ensure that healthcare professionals are utilizing their Electronic Medical Records system efficiently to improve healthcare quality and patient safety. English Rows Eye Care understands that this is very personal and sensitive information. We want to ensure you that this information will only be used as part of the Meaningful Use objectives.

Preferred Language:*

English

Spanish

Other

Race:*

Ethnicity*

Preferred Communication Methods:*

Postal Mail

Telephone

Authorization

I have reviewed the information on this form and it is accurate to the best of my knowledge. I understand that this information will be used by the Doctor to help determine appropriate treatment. If there is any change in my medical status, I will inform the Doctor.
I authorize my insurance company to pay English Rows Eye Care all insurance benefits otherwise payable to me for services and/or materials.
I understand that a quote of eligibility and benefits from my insurance company is not a guarantee of payment. All benefits are subject to eligibility, medical necessity and the terms, conditions, limitations and exclusions of my health benefit plan at the time services are rendered and that I am financially responsible for all co-pays, co-insurance and non-covered charges.
I authorize the use of this signature on all insurance submissions.
I authorize English Rows Eye Care to release all information necessary to secure the payment of benefits.
I acknowledge that I was offered/provided a copy of English Rows Eye Care’s Notice of Privacy Practices.

HIPAA Acknowledgement Date:*

MM slash DD slash YYYY

HIPAA Acknowledgement Typed Name*

First Last