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Hours & Locations
- Middletown
- Kearny
Our Eye Doctors
- The Staff
Eye Care Services
Eyeglasses
- Designer Frames
Contact Lenses
Insurance

Hours & Locations
- Middletown
- Kearny
Our Eye Doctors
- The Staff
Eye Care Services
Eyeglasses
- Designer Frames
Contact Lenses
Insurance

Middletown

Request Appointment

Call 732-671-7451

Kearny

Request Appointment

Call 201-474-2020

Home » New Patient Form

New Patient Form

Date:
MM slash DD slash YYYY
Patient Name:
First Last
DOB:
MM slash DD slash YYYY
Address:
Street Address City State ZIP Code
Email:
Phone:
Cell Phone:
Date of Last Eye Exam:
MM slash DD slash YYYY
Social Security Number:
Primary Physician:
Date of Last Medical Exam:
MM slash DD slash YYYY
Occupation:
Hobbies:
Are you currently pregnant or nursing?
- Yes
- No
- N/A
Glasses
Do you wear glasses?
- Yes
- No
Are they for Near Vision?
- Yes
- No
Are they for Distance Vision?
- Yes
- No
Any problems with Near Vision with our without glasses?
- Yes
- No
Any problems with Distance Vision with our without glasses?
- Yes
- No
Contact Lenses
Do You Wear Contacts?
- Yes
- No
What type of Lenses do you wear?
- Soft
- Disposable
- Dailies
- Extended Wear
- Bifocal
- Gas Permeable
- Hard Lenses
Are you happy with your current lenses:
- Yes
- No
Wearing Schedule:
- Daily
- Overnight
Solution Used:
VISUAL CONCERNS:
HEADACHES:
- Yes
- No
How long have you had them?
PAIN IN EYE:
- Yes
- No
Please specify:
- Right
- Left
- Both
Where is Pain Located:
How Long?
DOUBLE VISION:
- Yes
- No
SPOTS:
- Yes
- No
FLASHES:
- Yes
- No
DRY EYES:
- Yes
- No
BURNING EYES:
- Yes
- No
OTHER:
- Yes
- No
If other, please specify:
PRIOR DIAGNOSES OR PROBLEMS:
Personal Medical History (Review of Systems):
Please check if any of the following applies to you past or present and list all medications below.
If you have none of these conditions, please check NONE.
Cardiovascular:
- None
- High Blood Pressure
- High Cholesterol
- Heart Disease
- Vascular Disease
- Stroke
- Other
If other, please specify:
Endocrine:
- None
- Type 2 Diabetes
- Type 1 Diabetes
- Thyroid Problem
- Hormonal Dysfunction
- Other
If other, please specify:
Constitutional:
- None
- Cancer
- Trauma/Large Volume Blood Loss
- Developmental Disability
- Other
If other, please specify:
If cancer, please specify the type:
Respiratory:
- None
- Asthma
- Bronchitis
- Emphysemia
- COPD
- Other
If other, please specify:
Neurological:
- None
- Multiple Sclerosis
- Epilepsy/Seizure Disorder
- Cerebral Palsy
- Tumor
- Migraines/Headache Disorder
- Other
If other, please specify:
Musculoskeletal:
- None
- Arthritis
- Fibromyalgia
- Muscular Dystrophy
- Anklosing Spondylitis
- Other
If other, please specify:
Immunological:
- None
- AIDS or HIV
- Lupus
- Neurological
- Other
If other, please specify:
Heomatological:
- None
- Anemia
- Leukemia
- Other
If other, please specify:
Gastrointestinal:
- None
- Chrone's
- Colitis
- Other
If other, please specify:
Ear/Nose/Throat:
- None
- Hearing Loss
- Upper Respiratory Infection
- Other
If other, please specify:
Dermatologic:
- None
- Eczema
- Rosacea
- Psoriasis
- Skin Cancer
- Other
If other, please specify:
Allergies:
- None
Please List Allergies:
Drug/Medication: Environmental: Other:
Alcohol Use
- Yes
- No
Amount:
Tobacco Use
- Current
- Past
- Never
Amount:
Number of Years:
Please list any medications that you are taking:
(Including vitamin, herbs, supplements and over the counter)
FAMILY HISTORY:
Has anyone in your immediate family (grandparents, parents, siblings, children, living or deceased) been diagnosed with:
Lupus:
- Yes
- No
Relationship:
High Blood Pressure:
- Yes
- No
Relationship:
Diabetes:
- Yes
- No
Relationship:
Heart Disease:
- Yes
- No
Relationship:
Thyroid Disease:
- Yes
- No
Relationship:
Cancer:
- Yes
- No
Relationship:
If cancer, please specify the type:
Blindness:
- Yes
- No
Relationship:
Cataracts:
- Yes
- No
Relationship:
Glaucoma:
- Yes
- No
Relationship:
Crossed Eyes:
- Yes
- No
Relationship:
Macular Degeneration:
- Yes
- No
Relationship:
Retinal Detachment:
- Yes
- No
Relationship:
Other:
- Yes
- No
Relationship:
If other, please specify:
Patient Signature
Date
MM slash DD slash YYYY

Δ

Schedule Appointment

Dr. Edward Maslansky

2 Apple Farm Road, Suite 3
Middletown, NJ 07701

Phone: 732-671-7451
Fax: 732-671-7216

Monday: 10:00 AM - 5:30 PM
Tuesday: 10:00 AM - 4:00 PM
Wednesday: 10:00 AM - 5:30 PM
Thursday: 10:00 AM - 5:00 PM
Friday: 10:30 AM - 5:00 PM
Saturday: 9:00 AM - 1:00 PM
Sunday: Closed

Dr. Edward Maslansky

399 Kearny Avenue
Kearny, NJ 07032-2603

Phone: 201-991-0026
Fax: 201-991-4989

Monday: 10:00 AM - 5:00 PM
Tuesday: 10:00 AM - 5:00 PM
Wednesday: 10:00 AM - 6:00 PM
Thursday: 10:00 AM - 6:00 PM
Friday: 10:00 AM - 5:00 PM
Saturday: 9:00 AM - 3:00 PM
Sunday: Closed

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What’s New

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Dr. Edward Maslansky - Located at 399 Kearny Avenue, Kearny, NJ 07032-2603. Phone: 201-991-0026 . https://www.maslanskyeye.com

Dr. Edward Maslansky - Located at 2 Apple Farm Road, Suite 3, Middletown, NJ 07701. Phone: 732-671-7451 . https://www.maslanskyeye.com

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