New Patient | Tyler Schremmer OD | Hoisington, KS

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Request a Call Back

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New Patient

New Patient Questionnaire

New Patient Form Page

Name:

Date of Birth:

Address:

Sex:

Male

Female

Phone (Home):

Phone (Business):

Spouse (if married):

Parent's Name (if child):

Grade (if student):

Occupation:

Employer:

Family Physician:

Last Physical Examination

Last Vision Examination:

Doctor:

Do you wear glasses?

Full Time

Near

Distance

Contact lenses?

Soft

Hard

HGP

Are you undergoing medical or dental treatment presently?

Free Text

GENERAL HEALTH HISTORY (CIRCLE YES OR NO)

1. Are you in good health?

YES

NO

2. Are you taking any medications at this time?

YES

NO

3. Do you often feel exhausted or fatigued?

YES

NO

4. Do you ever have painful or swollen joints?

YES

NO

5. Do you ever have chest pain on exertion?

YES

NO

6. Have you ever had an unusual reaction to a dental anesthetic, penicillin or sulfa drugs?

YES

NO

7. Are you prone to motion sickness?

YES

NO

8. (Women) Are you pregnant?

YES

NO

Free Text

Have you ever had any of the following? (Please check if answer is yes)

High blood pressure

Low blood pressure

Rheumatic fever

Diabetes

Heart trouble

Stroke

Sinus problems

Thyroid problems

Kidney problems

Multiple sclerosis

Glaucoma

Burning of eyes

Excessive tearing

Difficulty with swallowing

Serious eye injury

Artificial eye (indicate if right or left on the remarks section if answer is yes)

Frequent headaches

Vision blackouts

Double vision

Irritation from bright lights

Allergy problems

Constricted or tunnel vision

Cataracts

Flashes of light

Difficulty with distance vision

Difficulty with near vision

Itching of eyes

Pain around the eyes

Dry eyes

Difficulty with night vision

Eye surgery

Remarks:

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OUR LOCATION

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HOURS

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Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

This is a placeholder for the Yext Knolwedge Tags. This message will not appear on the live site, but only within the editor. The Yext Knowledge Tags are successfully installed and will be added to the website.

HOURS

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Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

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CONTACT US

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Hi. Do you need any help?

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