New Patient Form

Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Address:
City:		State/ZipCode	TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Single Married Separated Divorced Widowed Unknown	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Maanum, John	Misc/Guardian

Billing Information

Is The Billing Address different? If different, please fill out below.

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Address

City	State	ZipCode
	TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None AETNA BLUE CROSS CASH Cigna Davis Vision EYEMED MEDI-CAL MEDICARE MES New Insurance New Insurance NVA PRIVATE INS. Safeguard SPECTERA United Health Ins VSP Choice VSP EXAM PLUS ALLOWANCE VSP HEALTHY FAMILY VSP REGIONAL NETWORK VSP Signature VSP STATE OF CA VSP VALUE PLAN
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary

Insurance Information

Insurance Name:	None AETNA BLUE CROSS CASH Cigna Davis Vision EYEMED MEDI-CAL MEDICARE MES New Insurance New Insurance NVA PRIVATE INS. Safeguard SPECTERA United Health Ins VSP Choice VSP EXAM PLUS ALLOWANCE VSP HEALTHY FAMILY VSP REGIONAL NETWORK VSP Signature VSP STATE OF CA VSP VALUE PLAN
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Tertiary

Insurance Information

Insurance Name:	None AETNA BLUE CROSS CASH Cigna Davis Vision EYEMED MEDI-CAL MEDICARE MES New Insurance New Insurance NVA PRIVATE INS. Safeguard SPECTERA United Health Ins VSP Choice VSP EXAM PLUS ALLOWANCE VSP HEALTHY FAMILY VSP REGIONAL NETWORK VSP Signature VSP STATE OF CA VSP VALUE PLAN
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

Exam type

Eye exam - glasses Eye exam- contact lenses Eye exam - medical Office visit - red eye Contact lens follow up Rx check Glaucoma eval Glaucoma F/UP Dry eye evaluation Dry eye follow up

Reason for your visit:

annual eye health check visual blur through current SRx Visual blur - distance Needs new contacts Visual blur - near Visual blur - both Red Eye Headaches Injury Annual check for cataracts Flashing lights Increase in floaters Glasses broke Glaucoma exam Dry eyes Other: See notes

Ocular History

None Cataracts  Glaucoma Macular Degneration  Injury/Surgery Other

Medical History

None  Hypertension  High Cholesterol Diabetes Other

Systemic Medications:

None

Eye Medications:

None

Drug and Environmental Allergies:

None Sulfa Penicillin Erythromycin Iodine Codeine Pollen/ Dust Animal Dander NKDA

Family Med History:

None  Diabetes  High Cholesterol  Hypertension       Other

Family Eye History:

None  Macular Degeneration  Cataracts  Glaucoma   Other

Social History

Social Hx: Denies any tobacco, alcohol and drug use Tobacco User Alcohol Use: Social Alcohol Use: Constant

Last Eye Doctor

Primary Care Physician:

Last Medical Exam with PCP:

Unknown less than 1 year 1 year 2-3 years 4 or more years Never

Contagious Disease Exposure:

None Gonorrhea HIV/Aids Syphillus Hepatitis

Smoking Status

Never smoker (<100 lifetime cigarettes or equivalent quantity of cigar or pipe smoke) Former smoker (no longer smokes)">Former smoker (no longer smokes)">Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Smoker (current status unknown) Unknown if ever smoked Other

Preferred Language

English Spanish Other

Race

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Patient Declined to Specify

Ethnicity

Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify

No Known Drug AllergiesNo Known Medications

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