Step 1 of 8 12% Welcome to the office of Dr. Sam Pelletier at York Family EyecareToday's Date* MM slash DD slash YYYY Name* First Middle Last Date of Birth* MM slash DD slash YYYY If under 21, parents’ names: Address* Street Apt. City 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 State Zip Home Phone*Mobile Phone*Home Email Address* Enter Email Confirm Email Occupation* School (if applicable) Grade Level (K-12) Last Eye Doctor Seen (Enter N/A if not known)* Approx. Date of Visit MM slash DD slash YYYY Whom may we thank for referring you? (Enter N/A if not known)* Their relationship to you* Family Member Friend Acquaintance Colleague Vendor NA Was there something about the source, or the mention of York Family Eyecare, that particularly impressed you?How did you hear about us?* Other Doctor Insurance Company Internet Search YFE Website Dr. P's Blog YFE Facebook Page Facebook Advertisement Other Social Media Platform/Mention Online Review Online Advertisement Online News Story Print Advertisement Print News Story YFE Email Other YFE Mailing School Screening Community Event Any Other Source Your Ocular Status and History - Part 1Do you wear eyeglasses?* Yes No Do you wear contact lenses now?* Yes No Are you interested in trying contact lenses today?* Yes No Do your eyes ever feel dry or uncomfortable?* Yes No Are you bothered by changes in your vision throughout the day?* Yes No Are you ever bothered by red eyes?* Yes No Do you ever use or feel the need to use eye drops?* Yes No Your Ocular Status and History - Part 2Do you now have, or have you ever had: (please mark all that apply)* Distance Blur Computer Blur Near Blur Headaches/Migraines Double Vision Crossed Eye/Eye Turn Lazy Eye Uncomfortable Glasses Trouble Seeing While Driving at Night Sunlight Sensitivity Burning Occasional Dryness Tearing Grittiness Itchiness Flashes of Light Floaters/Spots Cataracts Glaucoma Macular Degeneration (AMD) Retinal Detachment Corneal Abrasions Iritis/Uveitis Eye Infections Eye Injury Other Eye Disorders None of the above Have you ever smoked?* Yes No If so, please list dates:* Please list all allergies (Enter N/A if not known):*Please list your medications (Enter N/A if not known): Please check all known health conditions, and indicate how long for each diagnosis. - Part 1Cardiovascular* Chest Pain High Blood Pressure High Cholesterol Irregular heartbeat Pacemaker Other None of the above Because you checked "Other", please provide more information.* Constitutional* Chronic Fatigue Frequent Dizziness Other None of the above Because you checked "Other", please provide more information.* Endocrine* Diabetes Thyroid Disorder Other Hormonal Disorders None of the above Because you checked "Diabetes", please answer the following questions:What is average Blood Sugar?* Fasting?* What is your HbA1c reading?* Because you checked "Other Hormonal Disorders", please provide more information.* Gastrointestinal* Crohn’s Disease Irritable Bowel Other None of the above Because you checked "Other", please provide more information. Genitourinary* Kidney Disease Prostate Disease Other None of the above Because you checked "Other", please provide more information. Hematology/Oncology* Cancer Other None of the above Because you checked "Cancer", please answer the following questions:Where is the primary site?* What is the approximate date of diagnosis?* Are you currently under treatment?* Because you checked "Other", please provide more information.* Please check all known health conditions, and indicate how long for each diagnosis. - Part 2Integumentary/Immunological* Rosacea Rash Sarcoidosis Lupus Other None of the above Because you checked "Other", please provide more information.* Mental Health* Anxiety Depression Other None of the above Because you checked "Other", please provide more information.* Musculoskeletal* Fibromyalgia Trauma/Injury Rheumatoid Arthritis Other None of the above Because you checked "Other", please provide more information.* Neurological* Headaches Migraines Stroke Numbness/Tingling Poor Coordination/Balance Multiple Sclerosis Other None of the above Because you checked "Other", please provide more information.* Respiratory* Asthma Emphysema Shortness of breath Frequent/Persistent Cough Tuberculosis Smoker (Past or Present) Other None of the above Because you checked "Other", please provide more information.* Family History* Glaucoma Macular Degeneration Retinal Tear, Hole, or Detach Blindness Misaligned Eyes Color Vision Problems Other None of the above Because you checked "Other", please provide more information. Please list skills or hobbies with specific visual requirements, i.e. computer, reading, driving, sports, etc. (Enter N/A if none)*Is there anything else about your eyes that we should know?Please list your other health care providers, so we can communicate with them as needed. Include any professional who supports your wellness: therapists, chiropractor, acupuncturist, nutritionist, personal coach, etc.Primary care provider (PCP): Specialist: Specialist: Specialist: Practitioner: Practitioner: Practitioner: DID YOU KNOW that we have a thank-you program for referrals? Anytime you recommend York Family Eyecare to someone you know, and they become a new patient, you will receive the gift card of your choice! You will also be entered in our quarterly drawing for $100 gifts! It’s our way of expressing our gratitude, while supporting other quality York businesses, and Maine’s economy.So now for the fun part. Tell us...after you refer someone to us, which gift card(s) would you be most excited to receive? Please check off your top three. Anthony’s Food Shop Coppa Magica (seasonal gelato) Daisy Trading Co. Eldredge Just Write Rossi’s Italian Bakery Stonewall Kitchen The Central Restaurant The Village Scoop Wild Willy’s Write in your favorite! THANK YOU for helping us provide you with the most personalized eye care on the Seacoast.CommentsThis field is for validation purposes and should be left unchanged.
