Weber Patient Intake
Weber Eye Care
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Patient information
Patient first name
Middle initial
Patient last name
Preferred name
Date of birth
Sex
Female
Male
Non-binary
Prefer not to say
Other
Marital status
Single
Married
Divorced
Widowed
Other
Occupation
Contact information
Phone number
Email
Address
Address line 2
City
State
ZIP code
Preferred contact method
Text
Phone
Email
I agree the office may contact me by text about my care.
Emergency contact name
Emergency contact relationship
Emergency contact phone
Visit and insurance
Reason(s) for visit
Comprehensive eye exam
Contact lens exam
Glasses or vision change
Eye irritation or redness
Eye pain or injury
Dry eye
Diabetic eye exam
Follow-up or medical eye care
Neurolens, headaches, or eye strain
Other
Tell us more about today's visit
Vision insurance
Medical insurance
Vision insurance card front
Vision insurance card back
Medical insurance card front
Medical insurance card back
Member ID
Group number
Insurance phone number on card
Secondary insurance
Policy holder name
Policy holder date of birth
Relationship to insured
Policy holder employer
Policy holder address same as patient?
Yes
No
Policy holder address
Policy holder address line 2
Policy holder city
Policy holder state
Policy holder ZIP code
Does your plan require a referral?
No
Yes
Not sure
Does your plan require prior authorization?
No
Yes
Not sure
How did you hear about us?
Medical history
Current medications
Medication allergies
Current or past medical conditions
Diabetes or high blood sugar
High blood pressure
Heart disease
Cholesterol problems
Thyroid problems
Asthma or COPD
Autoimmune condition
Cancer
Migraines or headaches
Pregnant or nursing
Other
Medical history details
Family medical or eye history
Diabetes
Glaucoma
Macular degeneration
Retinal detachment
Blindness
Cataracts
High blood pressure
Heart disease
Other
Family history details
Tobacco use
Never
Former
Current
Alcohol use
No
Occasional
Regular
Recreational drug use
No
Yes
Eye history
Eye conditions or symptoms
Cataracts
Glaucoma or glaucoma suspect
Macular degeneration
Diabetic retinopathy
Dry eye
Eye allergies
Eye injury
Floaters, flashes, or spots
Retinal tear or detachment
Eye surgery
LASIK or PRK
Lazy or crossed eye
Other
Eye history details
Last eye exam
Do you wear glasses?
Yes
No
Do you wear contact lenses?
Yes
No
Contact lens brand or prescription details
Interested in contact lenses?
Yes
No
Maybe
Eyewear and lifestyle
Important visual needs
Computer or desk work
Dual or large monitors
Night driving
Outdoor activities
Sports or recreation
Safety glasses
Reading or close work
Frequent indoor/outdoor changes
Lens or frame interests
Anti-glare
Transitions or light-responsive lenses
Blue light support
Progressive lenses
Prescription sunglasses
Safety glasses
Value price
Use insurance benefits
Problems with current glasses or contacts
Additional information
Preferred appointment days or times
Have you completed the Neurolens lifestyle screening?
Yes
No
Not sure
Anything else the office should know?
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