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Patient Registration 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.

Patient Information

First name

Last name

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Phone Number

Daytime Phone

Cell Phone

Email Address

Personal Information

Gender*

Female

Male

Date of Birth*

Month

Day

Year

Preferred Language*

Race*

Ethnicity*

Marital Status

Employment Status

Employer

Occupation

How were you referred to our office?

Communication Preference

Eye History

Please check off any current conditions you suffer from.

I stopped wearing glasses

I stopped wearing contact lenses

Headaches

Glare/Light Sensitivity

Tired Eyes

Amblyopia (lazy eye)

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

Strabismus (crossed eye)

Blurred Vision at Distance

Blurred Vision at Near

Haloes

Double Vision

Floaters or Spots

Fluctuating Vision

Loss of Vision

Loss of Side Vision

Glasses History

Do you wear glasses?*

Yes

No

Contact Lens History

Do you wear contact lenses?*

Yes

No

Medical History

When, approximately, was your last eye exam?

Where did you get your last eye exam?

When, approximately, was your last physical exam?

Who is your primary care physician?

Do you drink alcohol?

Do you smoke?

Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)

Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)

Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)

Please list all hospital surgeries you have ever had:

Please list all prescription and over-the-counter medications you take and for what conditions

Please list all drug allergies you have

Please check off any current conditions you suffer from

Chronic fever, unexpected weight loss/gain, fatigue

Ear/nose/throat problems ( eg. Hearing loss, sinus problems, sore throat)

Heart problems (eg. Chest pain, irregular heart beat, swelling of feet, cold hands or feet)

Respiratory problems (eg. Shortness of breath, wheezing, coughing)

Gastrointestinal problems (eg. Heartburn, abdominal pain, diarrhea, vomiting)

Genitourinary problems (eg. Painful urination, blood in urine, sex organ problems)

Musculoskeletal problems (eg. Muscle aches, joint pain, swollen joints)

Skin problems (eg. Rashes, excessive dryness, growths or lumps)

Neurological problems (eg. Numbness, weakness, headaches, “blackouts”)

Psychiatric problems (eg. Depression, anxiety)

Endocrine problems (eg. Frequent urination, thirst, feeling hot or cold all the time)

Blood/Lymph problems (eg. Bruising, weakness, unusual paleness, swollen glands)

Immune problems (eg. Frequent infections, allergic reactions to foods, dust, pollens)

Primary Insurance

Please bring all insurance cards with you to your appointment.

Insurance Company Name

Insurance Company Phone Number

Address

Country/Region

Address

City

Zip / Postal code

Insured's Name

Identification Number

Group Number

Insured's Date of Birth

Month

Day

Year

Patient's Relation to Insured

Secondary Insurance

Do you have secondary insurance?

Yes

No

Comments

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Date*

Month

Day

Year

Eye Q Optical

104-23 Queens Blvd
Forest Hills, NY 11375

Phone: 718-275-2500

Phone: 718-690-3250

Email: eyeqoptical@gmail.com
(Do not send personal health
information by email.)

Email: eyellusion@gmail.com
(Do not send personal health
information by email.)

Monday: 10:00 AM - 6:00 PM

Tuesday: 10:00 AM - 6:00 PM

Wednesday: 10:00 AM - 6:00 PM

Thursday: 10:00 AM - 6:00 PM

Friday: 10:00 AM - 6:00 PM

Saturday: 10:00 AM - 6:00 PM

Sunday: Closed

Eye Q Optical 104-23 Queens Blvd, Forest Hills, NY 11375
Phone: 718-690-3250
https://www.eyeq-optical.com

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