-New Patient History - Optik PDX

Thank you for choosing Optik PDX and Dr. Ezra Atikune. Please complete this e-form so we may better understand your eyecare needs. Privacy of personal information is very important to us. We will only use the information for the optometric services and products that we provide.

Patient Information

Mr/Mrs/Ms/Miss/Dr

First Name *

Middle Name

Last Name *

Nickname

Birth Date (MM/DD/YYYY) *

Address *

Apt/Suite

City *

State *

Zip Code *

Phone/Mobile number *

Email *

Emergency contact: Name and Phone number *

Emergency contact's relationship *

Occupation

Hobbies

Do you wear Sunglasses?

Yes. Are they prescriptions? Yes. Are they prescriptions?

Do you have an East/West commute?

Yes

How much time do you spend outdoors?

How did you hear about us?

Do you have Vision or Medical Insurance? *

No, I will private pay.

Yes, my insurance and policy number is Yes, my insurance and policy number is

Do you participate in a Flex Spending Account(FSA or HSA)?

Yes, I would like to use my benefit.

Last Eye Exam

Previous Doctor

Do you currently use?

Eyeglasses

Contact Lenses

Nothing, but maybe I should

Reason for Visit

Are you experiencing any of the following?

Ocular and Medical History

Cataracts

Self

Family

Glaucoma

Self

Family

Macular Degeneration

Self

Family

Lazy Eye

Self

Family

Other

High Blood Pressure

Self

Family

Diabetes

Self

Family

High Cholesterol

Self

Family

Heart Problems

Self

Family

Thyroid

Self

Family

Other

Please list ALL current medications/vitamins/supplements

Please list ANY allergies

Questions or comments

Thank you for taking the time to fill out this form. We are truly looking forward to seeing you!

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Comprehensive Eye Exam	Contact Lens Exam
Medical/Red Eye	Laser Consultation
Other Other

Problems seeing far away/TV/driving	Frequent Headaches/Migraines
Problems seeing newpapers/books	Double Vision
Problems seeing Computer screen	Sudden Loss of Vision
Dry eyes	Discomfort/Irritation
Redness