SpectOcular Patient Intake
Please complete both sides in ink. Your answers are reviewed with you before anything is entered into your record.
About you
First name
Last name
Date of birth (MM/DD/YYYY)
Email
Phone
Preferred way to reach you
Phone callText messageEmailNo preference
Street number
Street name
Apartment / suite
City
State
ZIP
Your primary care doctor (PCP)
Don't know — office will ask at the visit
PCP first name
PCP last name
Street number
Street name
City
State
ZIP
Phone / fax (if known)
Your pharmacy
Don't know — office will ask at the visit
Pharmacy name
Phone (if known)
Street number
Street name
City
State
ZIP
Background
Race / ethnicity — check all that apply
American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhitePrefer not to answer
Biological sex
MaleFemalePrefer not to answer
Smoking
Never smokerFormer smokerCurrent smokerPrefer not to answer
Weight (lb)
Height (ft / in)
Has a doctor ever told you that you have…
Diabetes?
NoYesDon't know
High blood pressure?
NoYesDon't know
Kidney problems?
NoYesDon't know
If yes — what kind of kidney problem?
Don't knowChronic kidney diseaseDiabetic kidney diseaseBP-related kidney diseaseKidney stonesPolycysticGlomerulonephritisOnly one kidneyOn dialysisTransplantOther
Name of the kidney disease, if you know it
Heart and circulation — check any a doctor has told you that you have
Heart attackStroke or TIAAtrial fibrillationHeart failureHigh cholesterolNone of the above
Brain and nerves — check any a doctor has told you that you have
Parkinson's diseaseAlzheimer's / dementia / memory problemsMultiple sclerosisMigraineSeizure or epilepsyConcussion or head injuryNone of the above
STAFF USE ONLY
Measured BP — systolic
Diastolic
Date
Staff initials
Entered into system (date / by)