New Patient Form

Demographics

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

Address:
City:		State/ZipCode	CA

Home Phone:		Work Phone:
Other Phone:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female
Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Miss Master Dr.

Address

City	State	ZipCode
	CA

Home Phone:
Work Phone:

Medical History

VISUAL HISTORY:
How long since last eye exam? 1 year 2 years 3-4 years 5-6 years 7 or more years Never

Have you ever worn contact lenses? YesNo     
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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): none Artificial Tears/Lubricating drops Allergy drops Glaucoma medications Antibiotic drops Steroid drops Other

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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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)	No Yes
Lazy Eye (Amblyopia)	No Yes
Glaucoma	No Yes
Macular Degeneration	No Yes
Retinal Detachment	No Yes
Eye Injury	No Yes
Eye Surgery	No Yes
List any eye surgeries:	none Cataract Surgery Refractive Laser Surgery Glaucoma Surgery Pterygium Removal Eyelid Surgery

Are you currently experiencing any of the following?

Double Vision	No Yes
Eyes "hurt" or "tired"	No Yes
Irritated Eyes	No Yes
Flashing lights	No Yes
Dry Eyes	No Yes

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

General:	None Negative fatigue sick weight loss Other	Ear/Nose/Throat:	None Allergies Chronic Cough Dry Throat / Mouth Hard of Hearing Sinus Problems Other
Skin:	None exzema growths pimples, warts psoriasis rash skin cancer Other	Cardiovascular:	None High BP Heart condition Heart surgery Vascular Disease Other
Respiratory:	None Asthma Bronchitis Emphysema COPD Other	Musculoskeletal:	None arthritis cramps fibromyalgia joint pain osteoporosis spine stiffness swelling Other
Psychiatric:	None anxiety/depression insomnia other psychiatric Other	Gastrointestinal:	None Acid Reflux Constipation Crohn's disease Diarrhea Diverticulitis Ulcer Other
Endocrine:	None diabetes type 1 diabetes type 2 hypothyroid hyperthoyroid Other	Blood/Lymph:	None bleeding High cholesterol anemia Other
Neurological:	None headache migraines numbness, paralysis seizures stroke Other	Genitourinary:	None painful urination frequent urination impotence kidney disease yellow jaundice Other
Immune:	None asthma autoimmune disease HIV itching lupus other allergies seasonal allergies swelling Other

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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

Condition	Yes Or No	: RELATIONSHIP TO PATIENT
Blindness	No Yes	No Parents Siblings Grandparents Other
Eye turn (Strabismus)	No Yes	No Parents Siblings Grandparents Other
Glaucoma	No Yes	No Parents Siblings Grandparents Other
Macular Degeneration	No Yes	No Parents Siblings Grandparents Other
Retinal Detachment/Disease	No Yes	No Parents Siblings Grandparents Other

Condition	Yes Or No	: RELATIONSHIP TO PATIENT
Cancer	No Yes	No Parents Siblings Grandparents Other
Diabetes	No Yes	No Parents Siblings Grandparents Other
Heart Disease	No Yes	No Parents Siblings Grandparents Other
High Blood Pressure	No Yes	No Parents Siblings Grandparents Other
Thyroid Disease	No Yes	No Parents Siblings Grandparents Other
Other Inherited Disease	No Yes	No Parents Siblings Grandparents Other

If yes, what disease?

Lifestyle

New Patients Only
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?   Ad in Mail Another Doctor Dr. Wirta or Kurteeva Friend/Relative Insurance List Saw Office Sign Web Page Yellow Pages None Other

Do you..... (check box if your answer is yes)
...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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