Name: Westwood, NJ
Address: 219 Old Hook Road, Westwood, NJ, 07675, US
Telephone: (201) 664-0847
Price range: $000 - $300

Patient Information
Thank you for choosing Valley Eye Associates for you eyecare needs. Please complete this form in ink. If you have any questions or concerns, please do not hesitate to ask for assistance. We will be happy to help you.
*All fields with an star are required.
Today's Date*
MM slash DD slash YYYY
Name*
Prefix First Middle Last
Sex
- Female
- Male
SSN
Date of Birth*
MM slash DD slash YYYY
Age
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone
Work Phone
Cell Phone*
Would you like to receive text confirmations?
- Yes
- No
Preferred Phone Number
Race
- African American
- Asian
- Hispanic
- American Indian
- Caucasian
- Pacific islander
Marital Status
Employer Name & Address
Position/Department
Spouse/Parent's Name
Spouse/Parent's Work/Cell Phone
Student
- Yes
- No
Name of School
Guarantor (Person Financially Responsible)
If Self: Skip this section.
Name
First Last
Relationship to Patient
- Parent
- Spouse
- Other
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Medical Insurance Information
Primary Insurance*
Primary Policy Holder*
Member ID*
Primary's SS#*
Primary's Date of Birth*
MM slash DD slash YYYY
Secondary Insurance
Primary Policy Holder
Member ID
Primary's SS#
Primary's Date of Birth
MM slash DD slash YYYY
Vision Insurance
Vision Insurance Provider
Policy or ID Number
Patient Medical History & Review of Systems
Medical Doctor
Medical Doctor's Phone
Date of Last Physical
MM slash DD slash YYYY
Date of Last Eye Exam
MM slash DD slash YYYY
Chief Complaint*

How can we help you today? In this space, please briefly tell us any signs and symptoms you are experiencing.(Medical insurance will only cover your visit if there is a medical reason for the exam such as loss of vision, headaches, eye redness, eye pain, floaters, dry eye, eye itching or burning, glaucoma, cataracts, etc)
History of Present Illness
Which eye has a problem?
- Right Eye
- Left Eye
- Both Eyes
Does the problem cause vision loss or blur?
- Loss
- Blur
Did the problem occur suddenly or gradually?
- Sudden
- Gradual
How severe is the problem?
- Mild
- Moderate
- Severe
Is it worse at any specific distance?
- Distance
- Near
- Both
How long does it last?
- Intermittent
- Constant
How long has the problem been occuring?
- Short Term
- Long Term
Are there associated symptoms?
- No
- Headaches
- Nausea
Does anything help the problem?
- Nothing helps
- Nothing has been tried
Glasses & Contacts
Are you thinking of getting GLASSES today?*
- Yes
- No
Are you thinking of getting CONTACTS today?*
- Yes
- No
Do you currently wear glasses?
- Yes
- No
When do you wear your glasses?
- All the Time
- Reading/Near Work Only
- Computer Work
- Work Safety
- Distance Tasks Only
- Driving
- Other
Please Explain
Have you ever worn contacts?
- Yes
- No
Brand
Contact Lens Solution Used
Are you interested in wearing contact lenses?
- Yes
- No
What style?
- Soft
- Gas Permeable
- Extended Wear
- Bifocal
- Color
- Disposable
- Astigmatic
- Unsure
Do you work at a computer or video display terminal?
- Yes
- No
In which hobbies or sports do you participate?
Medical Information
Please Check any conditions that apply to you:
- Allergies (seasonal)
- Allergies (environmental)
- Drug Allergies (please list below)
- Pregnant
- Have given birth in last 6 months
- Breastfeeding
- Sinus Trouble
Do you currently take any medications?*
- No
- Yes
Please list current medications:
Name, Dosage and Frequency.
Do you have any drug allergies?*
- Yes
- No
Please list all known drug allergies:
Please list any major surgeries or hospitalizations:
Past Ocular History
Please select all that apply:
- Cataracts
- Glaucoma
- Macular Degeneration
- Diabetic Eye Disease
- Retinal Detachment
- Lazy Eye
- Eye Surgery
- Laser Treatments
- Eye Injury
- Chemo/Radiation
- Severe Ocular Pain
- Sensitivity to Light
- Floaters or Spots
- Flashes of Light
- Poor Distance Vision
- Poor Near Vision
- Eye Infection or Disease
- Double Vision
- Eye Burn, Itch, or Water
- Eye Strain
- Other
Please explain:
Family Ocular/Medical History
Please select all that apply:
- Glaucoma
- Cataracts
- Macular Degeneration
- Retinal Detachment
- High Blood Pressure
- High Cholesterol
- Diabetes
- Thyroid Problems
- Heart Disease
- Cancer
- Other
Please explain:
Social History
Smoking
- No
- Yes
Packs a day
Years
Alcohol
- No
- Social
- Occasional
- Heavy
Drinks per day:
Review of Systems
Please select all that apply or fill in the blank for those not listed.
Constitutional
- Flu
- Fever
- Fatigue
- Headache
- Recent Weight Change
Select if you currently have.
Endocrine
- Thyroid
- Diabetes
- Other
Year diagnosed:
Other:
Ears, Nose, Throat
- Hearing Problems
- Sinus
- Throat
Genitourinary
- Prostate Problems
- Kidney Stones
- Hysterectomy
Cardiovascular
- Chest Pain
- Palpitations
- High Blood Pressure
- High Cholesterol
- Heart Failure
- Pace Maker
- Heart Attack
- Angioplasty/Bypass
- Valve Disease
- Carotid Artery Disease
Neurological
- Stroke
- Weakness
- Seizure
- Multiple Sclerosis
Skin
- Rash
- Itch
- Lesion
- Growth/Tumors
Respiratory
- Shortness of Breath
- Asthma
- Emphysema
- Cough
- Bronchitis
- Pneumonia
- Tuberculosis
Psychiatric
- Dementia
- Alzheimer's
- Depression
- Anxiety
- Schizophrenia
- Bipolar
Hematologic
- Anemia
- Sickle Cell
- Bleeding Abnormality
- Elevated Cholesterol
Gastrointestinal
- Heartburn
- Bowel Problems
- Inflammatory Bowel Disease
- Gall Bladder Problems
- Hepatitis
Musculoskeletal
- Joint Pain
- Rheumatoid Arthritis
- Back Pain
- Fractures
- Marfan's Syndrome
- Ankylosing Spondylitis
Immunology
- Immune Deficiency
- Lupus
- Sjogren's
- Other
Please Explain Other:
Cancer
- Yes
- No
Type:
HIV Exposure
- Yes
- No
STD Exposure
- Yes
- No
Type:
Authorization
I certify that I have read and understood the above information to the best of my knowledge. I certify that the above questions have been accurately answered to the best of my knowledge. I understand that providing incorrect information can be dangerous to my health. I authorize the doctor to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such eyecare to third party payers and/or health practitioners.*
Signature of Responsible Party
Date*
MM slash DD slash YYYY
Agreement of Responsibility
Please View Our Agreement of Responsibility Here
I have been informed by Valley Eye Associates and the Notice of Privacy Practices (see forms below) which contains a more detailed description of the uses and disclosures of my health information. I have been given the right to review and sign this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that Valley Eye Associates restricts how my private information is used or disclosed to carry out treatment, payment, or health care options. I also understand that Valley Eye Associates is not required to agree to my request restrictions, but if Valley Eye Associates does agree then it is bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, excluding the extent in which Valley Eye Associates has already taken action relying on this consent.*
Signature of Patient (Or Responsible Party)
Date*
MM slash DD slash YYYY
Payment Policy
Please View Our Payment Policy Here
I authorize the release of information to determine liability for payment and/or to obtain reimbursement. I understand that if my account is not paid directly, I am responsible for the full amount and may be charged all costs including attorney/collection agency fees incurred with collection of the amount due. I authorize the release of any medical information necessary to process claims and the release of payment to Valley Eye Associates or the physician rendering services.*
Signature of Patient (Or Responsible Party)
Date*
MM slash DD slash YYYY

Patient Information

Guarantor (Person Financially Responsible)

Medical Insurance Information

Vision Insurance

Patient Medical History & Review of Systems

History of Present Illness

Glasses & Contacts

Medical Information

Past Ocular History

Family Ocular/Medical History

Social History

Review of Systems

Authorization

Agreement of Responsibility

Payment Policy

IMPORTANT UPDATE: PLEASE READ ENTIRE MESSAGE