New Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Medical History

VISUAL HISTORY:
How long since last eye exam?

Have you ever worn contact lenses? YesNo      Do you currently wear contact lenses? Yes No     Rigid Gas Permeable Soft
What solution do you use?  What is your replacement schedule? 

How many years have you worn contacts?
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Please list any medications you are currently taking: Or check here if none


Please list all eyedrops you use (OTC and Rx):

What medications are you allergic to, if any: Or check here if none


(Women) Are you pregnant or nursing?Yes No
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SOCIAL HISTORY: New insurance protocols require that we gather the following information. This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.

Do you or have you used tobacco products?

Do you use illegal drugs?No Yes      Do you consume alcohol?No Yes

Your Ethnicity: Your Race: Your Preferred Language:

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If answers are left blank below, it will be assumed to be a negative response.

Do you have a history of any of the following?
Eye Turn (Strabismus)
Lazy Eye (Amblyopia)
Glaucoma
Macular Degeneration
Retinal Detachment
Eye Injury
Eye Surgery
List any eye surgeries:

Are you currently experiencing any of the following?
Headaches
Double Vision
Eyes "hurt" or "tired"
Irritated Eyes
Bothered by light / sun light
Eyes frequently red
Flashing lights
Floaters

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REVIEW OF SYSTEMS
DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?

GENERAL: Fever, weight loss, weight gain, fatigue?
SKIN: growths, rashes, acne, exzema, melanoma
NEUROLOGICAL: Headaches, migraines, seizures, numbness, paralysis
ENDOCRINE: Diabetes, Hypothyroid, Hyperthyroid, Cancer
LYMPHATIC/BLOOD: Anemia, High cholesterol, bleeding problems, lymphoma
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Autoimmune Disease, HIV, Allergy Shots, itching
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat, hearing loss
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD, lung cancer
CARDIOVASCULAR: High BP, Heart condition, Heart Surgery, Vascular Disease
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux, cancer
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence, cancer
BONES, JOINTS, MUSCLE: Athritis, Joint Pains, Spine or Neck Injury, cramps
PSYCHIATRIC: Depression, Anxiety, Insomnia, other psychiatric
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FAMILY HISTORY
Do you have any history of the following in any FAMILY members (parents, grandparents, siblings, children)?
Family history is unknown/adopted

             NO YES : RELATIONSHIP TO PATIENT
Blindness

Eye turn (Strabismus)

Glaucoma

Macular Degeneration

Retinal Detachment/Disease

           No YES : RELATIONSHIP TO PATIENT
Cancer

Diabetes

Heart Disease

High Blood Pressure

Thyroid Disease

Other Inherited Disease

If yes, what disease?

Lifestyle

LIFESTYLE:
Very Important! New patients only. Who may we thank for referring you to our office?  Name of friend or relative: 

If not referred, how did you choose our office? 

Do you..... (check box if your answer is yes)
...work at a computer?
...have trouble with tilting your head if you have bifocals?
...think you might benefit from thinner, lighter lenses?
...have interest in an in-office trial of the latest contact lens designs?
...play recreational sports/outdoor activities?
...have problems with glare or reflections?
...have prescription sunglasses you use while driving?
...want information on Laser Vision Correction surgery?
...participate in a Flex Spending Account?
...have children?
...have family members in need of eye care?

What sports, hobbies, or activities do you enjoy? 

I have read and understand, to the best of my knowledge, the above information. I certify that all statements are truthful and accurate. I authorize the release of any information
concerning my (or my child's) health care, advice, and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I understand that I am
financially responsible for any service considered non-covered, any deductibles and/or co-payments as well as any servie denied due to non-participating provider.

Patient or Parent or Guardian signature: (type name here): 
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Submit Data

***After Completing All Forms "Submit Data" on Final Tab***