HomeOur DoctorsOur StaffEyecare ServicesFashion EyewearLens OptionsPatient FormsInsurances New Patient Intake Form Step 1 of 5 20% WILDWOOD EYECARE CENTERDonald J. Beilstein, O.D. and Muhajid A. Hines, M.D.Today's Date(Required)Patient Name First Middle Last Patient Mailing Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Date of BirthAgeGender Male Female Home PhoneWork PhoneCell PhoneEmail Enter Email Confirm Email OccupationEmployerSpouse or ParentLast Eye Exam DateVision Insurance and ID/Social Security NumberLast Medical Exam DateName of M.D.Medical InsuranceNote: A minimum deposit of 1/2 of your account is payable when prescription eyeglasses or contact lenses are ordered. The balance is due on delivery of the prescription.How will you settle your account today?We will only accept insurances and discounts at the time of the appointment. Check Cash Credit Card Medical HistoryDo you have allergies to medications? No Yes List Allergies:List any medications you are taking (including oral contraceptives, aspirin, over-the-counter medications, supplements, and home remedies):List all major injuries, surgeries, and/or hospitalizations:Select any that you have had: Crossed Eyes Lazy Eye Drooping Eyelid Prominent Eyes Dry Eye Macular Degeneration Glaucoma Retinal Disease Cataract Surgery Eye Infections Eye Injury Do you work at a computer for long periods? No Yes Do you have complaints about your glasses? No Yes Would you enjoy lenses that are thinner, lighter, and more comfortable? No Yes Are there times when you’d rather not wear contact lenses or glasses? No Yes Would you like information or a free evaluation regarding laser vision correction and your candidacy? No Yes Do you wear contact lenses? (If yes, complete prescription information is required to perform CL exam) No Yes Type of Lenses Soft Lenses Hard / Gas Permeable Lenses Lens Manufacturer: (i.e. Coopervision, Johnson & Johnson, Bausch & Lomb, Alcon)Lens Brand: (i.e. AquaClear, AcuVue, Ultra, etc.)Lens Type: (Sphere, Toric (for Astigmatism), or Multifocal)Lens Wear: (Daily, 1-2 week, Monthly, Extended)Prescription: "Power" (a + or – number such as -2.50), for Torics: Power, Cyl., Ax (or X).Lens Measurements: Base Curve (BC – i.e. 8.5) and Diameter (DIA – i.e. 14.5)Upload PrescriptionAccepted file types: jpg, png, pdf, Max. file size: 100 MB.Please list hobbies/interests: Family HistoryPlease note any family history (parents, grandparents, siblings, children; living or deceased) for the following:Blindness No Yes Unknown Relationship to YouCataract No Yes Unknown Relationship to YouCrossed Eyes No Yes Unknown Relationship to YouGlaucoma No Yes Unknown Relationship to YouMacular Degeneration No Yes Unknown Relationship to YouRetinal Detachment / Disease No Yes Unknown Relationship to YouArthritis No Yes Unknown Relationship to YouCancer No Yes Unknown Relationship to YouDiabetes No Yes Unknown Relationship to YouHeart Disease No Yes Unknown Relationship to YouHigh Blood Pressure No Yes Unknown Relationship to YouKidney Disease No Yes Unknown Relationship to YouLupus No Yes Unknown Relationship to YouThyroid Disease No Yes Unknown Relationship to YouOther No Yes Unknown Describe the Condition and the Relationship to You Social HistoryDo you drive? No Yes Do you have visual difficulty when driving? No Yes Please describe:Do you use tobacco products? No Yes Type / Amount / How long:Do you drink alcohol? No Yes Type / Amount / How long:Do you use illegal drugs? No Yes Type / Amount / How long:Have you ever been exposed to or infected with Hepatitis? No Yes Have you ever been exposed to or infected with HIV? No Yes REVIEW OF SYSTEMSAre you currently having any problems in the following areas?CONSTITUTIONAL:Fever No Yes Unknown SKIN DISORDERS/RASH (Integumentary):SKIN DISORDERS/RASH (Integumentary): No Yes Unknown NEUROLOGICAL:Headaches/Migraines No Yes Unknown Seizures No Yes Unknown EYES:Loss of Vision No Yes Unknown Blurred Vision No Yes Unknown Distorted Vision/Halos No Yes Unknown Loss of Side Vision No Yes Unknown Double Vision No Yes Unknown Dryness No Yes Unknown Mucous Discharge No Yes Unknown Redness No Yes Unknown Sandy or Gritty Feeling No Yes Unknown Itching No Yes Unknown Burning No Yes Unknown Foreign Body Sensation No Yes Unknown Excess Tearing/Watering No Yes Unknown Glare/Light Sensitivity No Yes Unknown Eye Pain or Soreness No Yes Unknown Chronic Infection of Eye or Lid No Yes Unknown Styes or Chalazion No Yes Unknown Flashes/Floaters in Vision No Yes Unknown Tired Eyes No Yes Unknown LASIK / PRK No Yes Unknown ENDOCRINE:Thyroid/Other Glands No Yes Unknown Weight Loss/Gain No Yes Unknown EAR, NOSE, MOUTH, THROAT:Sinus Congestion No Yes Unknown Runny Nose No Yes Unknown Chronic Cough No Yes Unknown Dry Throat/Mouth No Yes Unknown RESPIRATORY:Asthma No Yes Unknown Chronic Bronchitis No Yes Unknown Emphysema No Yes Unknown VASCULAR/CARDIOVASCULAR:Diabetes No Yes Unknown Heart Pain No Yes Unknown High Blood Pressure No Yes Unknown Vascular Disease No Yes Unknown Do you have a Pacemaker? No Yes Unknown GASTROINTESTINAL:Diarrhea No Yes Unknown Constipation No Yes Unknown URINARY:Kidney/Bladder Disease No Yes Unknown BONES/JOINTS/MUSCLES:Rheumatoid Arthritis No Yes Unknown Muscle Pain No Yes Unknown Joint Pain No Yes Unknown LYMPHATIC/HEMATOLOGIC:Anemia No Yes Unknown Bleeding Problems No Yes Unknown ALLERGIC/IMMUNOLOGIC:Seasonal Allergies No Yes Unknown PSYCHIATRIC DISORDERS:Memory Loss/Depression No Yes Unknown If you have a condition not listed, please explain:To prove that you are human please spell out the answer to seven plus four. Once you do that you will be able to submit this form.(Required)NameThis field is for validation purposes and should be left unchanged.
