New Patient Form

How old is the patient?

How did you hear about us?

Patient Full Name (first & last):

Nickname:

Select gender:

Address:

Phone Number:

Email:

Parent / Guardian Name's:

Relationship to patient:

Patient's school:

Patient's grade:

Hobbies:

Date of last eye exam:

Previous Doctor/Clinic:

Do you have glasses?

Do you have contacts?

Do you currently have any eye diseases?

List any eye injuries/surgeries:

Ear, nose, throat problems (sinus, ear infection, chronic cough, dry mouth, etc.)

Cardiac / Vascular problems (high blood pressure, heart pain, vascular disease, etc.):

Respiratory problems (asthma, emphysema, use of CPAP machine etc.):

Gastrointestinal problems (stomach ulcers, reflux, etc.):

Genital, kidney or bladder problems:

Muscle, bone or joint problems (arthritis, etc.):

Muscle, bone or joint problems (arthritis, etc.):

Skin problems (acne, warts, skin cancer, etc.):

Neurological problems (multiple sclerosis, migraines, seizures, etc.):

Psychiatric / social problems (anxiety, depression, bipolar, insomnia, etc.):

Endocrine problems (diabetes, thyroid disorder, pituitary tumor, etc.):

Blood/lymphatic problems (high cholesterol, anemia, etc.):

Allergic/immune problems (hay fever, lupus, Sjogrens, etc.):

Sustained a head injury or trauma/stroke?

Been in a car accident?

Been diagnosed with Autism or Spectrum Disorder?

Been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD)?

Been diagnosed with a learning disability or developmental disorder?

Had any surgeries?

Primary Care Physician's Name:

Clinic:

Last visit:

What is your current height?

What is your current weight?

Are you pregnant or nursing?

Has a neurological evaluation ever been performed?

List any medications you are allergic to:

List all prescription medications, vitamins, supplements, and over-the-counter medications you are taking:

How often do you use tobacco products?

How often do you drink alcohol?

How often do you use recreational drugs:

How many hours a day do you spend on screens? (cellphone, tablet, computer, television)

Which of the following describes your diet?

Blindness.

Glaucoma.

Cataracts.

Macular degeneration.

Eye turn (strabismus).

Lazy eye (amblyopia).

Retinal detachment.

Rheumatoid arthritis.

Cancer.

Diabetes.

High blood Pressure.

Heart disease.

Do you currently have any vision-related issues?

Do you currently have any eye comfort-related issues?

Do you currently have any motor-related issues?

Length of pregnancy:

Child's birth weight:

Type of delivery.

Child is.

During pregnancy of this child, did any of the following occur?

Please list any other complications during labor or when he/she was in utero:

Did he/she hit all developmental milestones at the appropriate time (creeping, crawling, walking, talking, etc.)?

Please list any other developmental concerns:

Has he/she experienced a traumatic event within the last year?

Is the child especially afraid of doctors?

Does the child understand / follow simple directions?

How does the child communicate?

What would you say your child's sociability is?

Is he/she in extracurricular activities or playing sports?

Does he/she like school?

Which of these categories has the child mastered?

How is he/she performing academically?

Which subject(s) does your child struggle with?

Does your child have trouble focusing during school or at home?

Is your child in any other therapies or tutoring?

May we collaborate with the above contact regarding your child's progress and challenge points?

Headaches with reading and writing.

Eyes burn, itch, or water.

Head tilt or closes one eye while reading.

Does not like reading or writing.

Hard to write in a straight line.

Poor reading comprehension.

Hard to pay attention when reading.

Gives up easily.

Work / visual tasks take a long time to complete.

Forgetful / poor memory.

Words run together or blur when reading.

Loses place while reading.

Hard to copy / read from board or distance.

Leaves out small words when reading.

Misaligns digits/columns of numbers.

Holds reading material very close.

Hard to complete assignments / work tasks on time.

Clumsy, trimps / bumps into things.

Daydreams.

Patients/Guardian name

My initial signifies that I am a non-Medicare patient and would like to opt-out of an out-of-network claim. Therefore, I do NOT want Neuro Eye Team to submit a claim to my insurance provider:

Release of Information

I agree to permit information from my examination records, or copies of my records, to be forwarded to other healthcare providers or insurance carriers upon written request or upon the recommendation of Alex Conley, O.D. when it is necessary for the treatment of my visual condition, my treatment process with Neuro Eye Team, or the processing of insurance claims.

Patients/Guardian name

Would you like to upload a photo (front and back) of your insurance card?