Name: CustomEyes
Address: 3660 NE Ralph Powell Rd, Lee's Summit, MO, 64064, US
Telephone: 816-524-7400
Price range: $000 - $300

Please fill out the patient history form and hit the submit button on the bottom of the page.

If you would prefer to print a copy of the form and fill it out by hand, you may do so by clicking here.

New Patient History Questionnaire

(Required for new patients and returning patients that have not been seen during the last three years)
Location*
Today's Date:
MM slash DD slash YYYY
Name:
First Middle Last
Home Phone:
Work Phone:
Cell Phone:
Address:
Street Address Address Line 2 City State ZIP Code
Would you like text notifications?
- Yes
- No
Employer:
Occupation:
Email:
Birth Date:
MM slash DD slash YYYY
Social Security #:
Race/Ethnicity:
Preferred Language:
Gender:
- Male
- Female
Who may we thank for referring you to our office?
Name of Medical Doctor:
City State
Where was your last eye exam?
Marital Status:
Spouse or Guardian (If Applicable):
Current Height:
Current Weight:
Reason for visit:
How would you like your prescription?*
- Paper
- Electronic (If electronic it will be sent to you through unencrypted email which is not secure and does not guarantee privacy. Do you still want it sent to you electronically?)
MEDICAL HISTORY
Do you have any allergies to medications?
- No
- Yes
If yes, list medication(s) & reaction below:
Medication Reaction
Do you have any non-medication allergies?
- No
- Yes
If yes, what?
List any medications you take (including oral contraceptives, aspirin, OTC medications, etc):
Medication Dosage Frequency Taken
List all major injuries, surgeries, and/or hospitalizations you have had:
Check any of the following that you have:
- Crossed Eyes
- Lazy Eye
- Drooping Eyelid
- Prominent Eyes
- Cataracts
- Glaucoma
- Iritis/Uveitis
- Eye Injury
- Macular Degeneration
- Retinal Disease or Detachment
- Eye Infections
- Keratoconus
- Corneal Problems
- Other Eye Disorders
If other, please specify:
Are you pregnant?
- No
- Yes
Are you nursing?
- No
- Yes
Do you wear glasses?
- No
- Yes
If yes, how old is your present pair of glasses?
Do you wear contact lenses?
- No
- Yes
If yes, how old is your present pair of lenses?
What brand of contacts do you wear?
Type of contact lenses:
- Rigid
- Soft
- Extended Wear
- Other
Are they comfortable?
- Yes
- No
FAMILY HISTORY
Please note any family history for the following conditions.
Relatives can be parents, grandparents, siblings, children: living or deceased.<br/? When listing relationship, if a grandparent, please specify maternal or paternal.
Blindness
- No
- Yes
Relationship to you:
Cataract
- No
- Yes
Relationship to you:
Crossed Eyes
- No
- Yes
Relationship to you:
Glaucoma
- No
- Yes
Relationship to you:
Macular Degeneration
- No
- Yes
Relationship to you:
Retinal Detachment or Disease
- No
- Yes
Relationship to you:
Cancer
- No
- Yes
Please specify the type of cancer and the relationship to you:
Diabetes
- No
- Yes
Relationship to you:
Heart Disease
- No
- Yes
Relationship to you:
High Blood Pressure
- No
- Yes
Relationship to you:
Kidney Disease/Stones
- No
- Yes
Relationship to you:
Lupus
- No
- Yes
Relationship to you:
Thyroid Disease
- No
- Yes
Relationship to you:
Arthritis
- No
- Yes
Relationship to you:
Other
- No
- Yes
Please specify condition and relationship to you:
SOCIAL HISTORY
Do you smoke?
- No
- Yes
Are you a former smoker?
- No
- Yes
Do you drink alcohol?
- No
- Yes
If yes:
- Daily
- Weekly
- Rarely
Do you use illegal drugs?
- No
- Yes
REVIEW OF SYSTEMS
Do you currently, or have you ever had any problems in the following areas?
Constitutional
No Yes
Extreme Weight Loss or Gain
Integumentary (Skin)
Neurological
No Yes
Headaches
Migraines
Seizures

Eyes

	No	Yes
Loss of Vision
Blurred Vision
Distorted Vision/Halos
Loss of Side Vision
Double Vision
Dryness
Mucous Discharge
Redness
Sandy or Gritty Feeling
Itching
Burning
Foreign Body Sensation
Excess Tearing/Watering
Glare/Light Sensitivity
Eye Pain or Soreness
Chronic Infection, Eye or Lid
Sties or Chalazion
Flashes/Floaters in Vision
Tired Eyes

Endocrine
No Yes
Thyroid
Elevated Cholesterol
Cancer
If cancer, please specify type:
Ears, Nose, Mouth, Throat
No Yes
Sinus Congestion
Chronic Cough
Dry Throat/Mouth
Allergies/Hay Fever
Respiratory
No Yes
Asthma
Chronic Bronchitis
Emphysema
Vascular/Cardiovascular
No Yes
Diabetes
Heart Pain
High Blood Pressure
Vascular Disease
Heart Disease
Diabetic Suspect
Gastrointestinal
No Yes
Colitis
Acid Reflux
Crohn's Disease
Genitourinary
No Yes
Kidney/Bladder
Musculoskeletal
No Yes
Rheumatoid Arthritis
Lymphatic/Hematologic
No Yes
Anemia
Bleeding Problems
Allergic/Immunologic
No Yes
Lupus
Fibromyalgia
Psychiatric
No Yes
Depression
Anxiety
BiPolar Disorder
If you answered yes to any of the above or have a condition not listed, please explain and list medications:
Patient Signature
Date
MM slash DD slash YYYY

Save and Continue Later

Medication	Reaction

Medication	Dosage	Frequency Taken

	No	Yes
Extreme Weight Loss or Gain
Integumentary (Skin)

	No	Yes
Headaches
Migraines
Seizures

New Patient History Questionnaire

(Required for new patients and returning patients that have not been seen during the last three years)

MEDICAL HISTORY

FAMILY HISTORY

SOCIAL HISTORY

REVIEW OF SYSTEMS

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