Patient Forms - Dussan Eye Care

Dussan Eye Care

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Patient Intake Form

* Indicates required field

First Name *

Last Name *

Phone Number *

Sex *

Male Female Prefer not to respond

E-Mail *

Address *

City *

State *

Zip Code *

Insurance provider *

Insurance ID *

Last 4 of SS# (if applicable) *

Do you currently wear *

Glasses Contact lenses Neither

Pharmacy Name *

Address *

City *

State *

Zip Code *

Phone *

Do you have any visual difficulty when reading? *

Yes No

Have you ever had eye surgery? *

Yes - Right Eye Yes- Left Eye No - Right Eye No - Left eye

Do you have any visual difficulty when seeing far away? *

Yes No

Have you ever injured your eyes? If yes, please describe *

Have you ever had or do you have any of the following eye conditions?

Currently *

Glaucoma Macular Degeneration Cataracts Retinal tear Lazy eye / eye patching Eye Pain Blurred/decreased vision Plaquenil Use Flashes of light in eye(s) Floating dark spots eyes Double Vision Halos Light Sensitivity Redness Itching Burning Dryness Sandy/Gritty eye(s) Foreign body sensation Discharge Crusting on eyelid Drooping eyelid

Past *

Glaucoma Macular Degeneration Cataracts Retinal tear Lazy eye / eye patching Eye Pain Blurred/decreased vision Plaquenil Use Flashes of light in eye(s) Floating dark spots eyes Double Vision Halos Light Sensitivity Redness Itching Burning Dryness Sandy/Gritty eye(s) Foreign body sensation Discharge Crusting on eyelid Drooping eyelid

Never *

Glaucoma Macular Degeneration Cataracts Retinal tear Lazy eye / eye patching Eye Pain Blurred/decreased vision Plaquenil Use Flashes of light in eye(s) Floating dark spots eyes Double Vision Halos Light Sensitivity Redness Itching Burning Dryness Sandy/Gritty eye(s) Foreign body sensation Discharge Crusting on eyelid Drooping eyelid

Medical History

Are you currently being treated for any of the following? *

High Blood Pressure Heart Disease Stroke Arthritis None Other

Other *

Have you ever been treated for any other serious illness or medical conditions or have had any hospitalizations or surgery? If yes, please explain: *

Do you have any drug allergies? if yes, please describe: *

Please list any medications that you take. prescription or over the counter or herbal remedies *

Chronic Fever, sudden weigth loss/gain, fatigue
Heart (e.g. chest pain, irregular heartbeat, hypertension)
Respiratory (e.g. cough, wheezing, shortness of breath)
Ear/nose/throat (e.g. hearing loss, sinus, sore throat
Gastrointestinal (e.g. heartburn, belly pain, diarrhea)
Urinary (e.g. pain, frequent urination, blood in urine)
Skin Problems (e.g. dry skin, rashes, dermatitis, itching)
Musculoskeletal (e.g. muscle aches, pain or swelling)
Endocrine (e.g. diabetes, thyroid)
Hermatologic/Lymphatic (e.g. leukemia, )
Psychiatric (e.g. depression, anxiety, confusion)
Neurological (e.g. numbness, weakness, headaches)

Are you currently experiencing problems with any of the following? *

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Social History

Martial Status *

Single Married Separated Divorced Widowed

Use of Alcohol *

Never Rarely Socially/moderate Daily

Use of Tobacco *

Never Former use Current

Use of recreational drugs *

Never Former use Current

Family Medical/Eye History (e.g. diabetes, glaucoma, retinal tears/detachment, macular degeneration)

Father
Mother
Siblings
Children

Medical/Eye Disease and approx. age at diagnosis *

Submit

Dussan Eye Care

1016 50th Avenue
Long Island City, NY 11101

Hours
Monday: 11 am - 6 pm
Tuesday: 11 am - 5 pm
Wednesday: 11 am - 6 pm
Thursday: 11 am - 5 pm
Friday: 11 am - 6 pm
Saturday: 11 am - 3 pm
Sunday: Closed

Contact Us

[email protected]

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