don't forget to blink!

New Patient Form

Welcome Hills Vision Studio

Dr. Vinal Patel, O.D.

PLEASE PRESENT ALL VISION AND MAJOR MEDICAL INFORMATION TO RECEPTIONIST

For Insurance Purposes:
​​​​​​​

Patient's Name:

Last Name *

First Name *

Date of Birth *

Last 4 SS# *

Sex *

Address *

City *

Zip *

Cell #

Home # *

Vision Insurance :

Medical Insurance

Email *

Note: It is now required we obtain an email address so we can upload your visit to the patient portal.
Responsible Member

Last Name *

First Name *

Date of Birth *

Last 4 SS# *

Sex *

Primary Language :

Special Needs

Race

Last PCP Visit *

PCP # *

Last Eye Exam *

Miscellaneous

List any previous surgeries with dates

Are you pregnant?

Hobbies/Recreational Sports you enjoy

How many hours per day do you use a computer?

Do you wear glasses?

Do you wear contact lenses? Brand

Are you interested in contact lenses?

Do you perform fine or close-up work?

Do you have trouble reading signs when driving at night?

Are you interested in refractive surgery?

Are you outdoors all or part of the time?

Are you sensitive in bright sunlight?

Are you bothered by glare from:

Overhead Lighting?

A computer screen?

Oncoming headlights at night?

Review of Systems

Do you currently have or have you ever had, any of the following problems or conditions?

Cardiovascular

Heart Disease

High Blood Pressure

High Cholesterol

Stroke

Vascular Disease

Ears/Nose/Mouth/Throat

Allergies

Sinus Congestion

Post Nasal Drip

Chronic Cough

Dry Mouth/Throat

Respiratory

Asthma

Chronic Bronchitis

Emphysema

Sleep Apnea

Gastrointestinal​​​​​​​

Constipation

Crohn’s Disease

Hepatitis A

Hepatitis B

Hepatitis C

Ulcer / Reflux

Genito-Urinary

Bladder / Genital / Kidney

Herpes Simplex

Prostate

Musculoskeletal

Joint / Muscle Pain

Osteo Arthritis

Rheumatoid Arthritis

Integumentary (skin)

Skin Cancer

Skin Disease

Herpes Zoster/Shingles

Neurological

Headaches

Migraines

Multiple Sclerosis

Gout

Seizures

Psychiatric

Anxiety / Depression

Endocrine​​​​​​​

Diabetes Type I

Diabetes Type II

Thyroid/Other Glands

Lymphatic – Hematologic

Anemia

Diabetes Type II

Bleeding Problems

llergic / Immunologic​​​​​​​

Eczema

Hives

Lupus

Organ transplant

Ocular History

(mark yes or no to each question)

Age-related macular degeneration

Amblyopia (Lazy Eye)

Vision Impaired - one eye

Vision Impaired - both eyes

Cataracts

Glaucoma

History of Refractive Surgery

Injury to the eye region

Keratoconus

Retinopathy

Strabismus (Crossed eyes)

Tear film insufficiency (dry eyes)

Other

Patient's Past Medical History

(mark yes or no to each question)

Acquired Immune Deficiency Syndrome (AIDS)

Arthritis

Asthma

Cancer

Chronic obstructive lung disease (COPD)

Diabetes mellitus

Emphysema

Heart Disease

Human immunodeficiency virus infection ( HIV)

Hypercholesterolemia (high cholesterol)​​​​​​​

Hypertensive disorder (hypertension)

Seasonal Allergy

Thyroid dysfunction

Mental Disorder

Rheumatoid arthritis

Family Health History

(mark yes or no to each entry. If yes, list which family member including mother, father, brother, sister, maternal/paternal, grandmother or maternal/paternal grandfather)

Amblyopia (Lazy eye)

Blindness and/or vision impairment

Cataract

Macular Degeneration

Glaucoma

Retinal Disorder

Strabismus (cross eyes)

Arthritis

Cancer

Diabetes mellitus

Hypertension (high blood pressure)

Cardiovascular disease

Stroke

Social History

(check one for each question)

Do you use recreational Drugs?

Are you a:

Tobacco Use​​​​​​​

(mark which one applies)

Medication

List all CURRENT prescriptions, over-the-counter prescriptions, eye drops, and dosages for each.

Medication Allergies

List any allergies you may have and reactions.

Pharmacy Name:

Telephone # *

Date *