New Patient Form

Demographics

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

Address:
City:		State/ZipCode	FL AL AK AZ AR CA CO CT DE DC 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 TX 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	Unknown Single Married Separated Divorced Widowed Child Engaged	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Hicks, Jesse Dr. Fisher, Jeffrey	Misc/Guardian

Billing Information

Is The Billing Address the Same?

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

Address

City	State	ZipCode
	FL AL AK AZ AR CA CO CT DE DC 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 TX UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None AARP Aetna American Medical and Life Insurance Co. American Republic Corp Avesis Banker's Life Blue Cross Blue Shield Carpenters Health and Security Plan of Western Washington Central States Health & Life Ins. Co. of Omaha Champ VA Cigna Davis EBS-RMSCO Evolutions First Health Life & Health Ins. Co. Freedom Health GEHA Gerber Life Insurance Company GHI Golden Rule Humana Medicare Supplement Local 400 Mail Handlers Benefit Plan Medicare MHBP Monumental Life Mutual of Omaha POMCO Principal Life Insurance Railroad Medicare Safeguard Spectera Superior Today's Options Tricare UMR UniCare State Indemnity Plan United American Insurance Company United Health Care USA Senior Care USAA Woodmen of the World WPS
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 AARP Aetna American Medical and Life Insurance Co. American Republic Corp Avesis Banker's Life Blue Cross Blue Shield Carpenters Health and Security Plan of Western Washington Central States Health & Life Ins. Co. of Omaha Champ VA Cigna Davis EBS-RMSCO Evolutions First Health Life & Health Ins. Co. Freedom Health GEHA Gerber Life Insurance Company GHI Golden Rule Humana Medicare Supplement Local 400 Mail Handlers Benefit Plan Medicare MHBP Monumental Life Mutual of Omaha POMCO Principal Life Insurance Railroad Medicare Safeguard Spectera Superior Today's Options Tricare UMR UniCare State Indemnity Plan United American Insurance Company United Health Care USA Senior Care USAA Woodmen of the World WPS
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:

Routine Vision

Insurance Information

Insurance Name:	None AARP Aetna American Medical and Life Insurance Co. American Republic Corp Avesis Banker's Life Blue Cross Blue Shield Carpenters Health and Security Plan of Western Washington Central States Health & Life Ins. Co. of Omaha Champ VA Cigna Davis EBS-RMSCO Evolutions First Health Life & Health Ins. Co. Freedom Health GEHA Gerber Life Insurance Company GHI Golden Rule Humana Medicare Supplement Local 400 Mail Handlers Benefit Plan Medicare MHBP Monumental Life Mutual of Omaha POMCO Principal Life Insurance Railroad Medicare Safeguard Spectera Superior Today's Options Tricare UMR UniCare State Indemnity Plan United American Insurance Company United Health Care USA Senior Care USAA Woodmen of the World WPS
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 AARP Aetna American Medical and Life Insurance Co. American Republic Corp Avesis Banker's Life Blue Cross Blue Shield Carpenters Health and Security Plan of Western Washington Central States Health & Life Ins. Co. of Omaha Champ VA Cigna Davis EBS-RMSCO Evolutions First Health Life & Health Ins. Co. Freedom Health GEHA Gerber Life Insurance Company GHI Golden Rule Humana Medicare Supplement Local 400 Mail Handlers Benefit Plan Medicare MHBP Monumental Life Mutual of Omaha POMCO Principal Life Insurance Railroad Medicare Safeguard Spectera Superior Today's Options Tricare UMR UniCare State Indemnity Plan United American Insurance Company United Health Care USA Senior Care USAA Woodmen of the World WPS
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

Who may we thank for referring you?

Insurance I noticed your location Google/search engine Your website Chamber of Commerce Yellow Pgs

Are any of your family already patients at Hicks Vision Care? If so please list.

What is your Occupation:

Student Retired Admin

Who is your Primary Care Physician or Medical Provier?

None

How long since your last eye exam:

1 year 2 years 3 years 4 years 5 years never years ago cannot remember

Have you ever had Contacts? If so, what kind?

soft disposable hard/rgp cannot remember

Are you interested in Contact Lenses?

Yes No

If you wear contacts, do you have back up glasses?

Yes No

Do you have a current pair of Sunglasses?

Yes No Transitions Clip ons OTCs Polarized

Are you interested in Safety Sunwear?

Yes No

Are you interested in Computer Progressive Eyeglasses?

Yes No

Are you Diabetic?

Yes No

If yes, for how long?

1 yr 2-5 yrs 6-10 11-15 yrs 16-20 yrs 20+ yrs

Are you Pregnant Or Nursing?

No Yes Unsure

On average, how many hours per day are you using a computer?

0 1 2 3 4 5 6 7 8 8+

Do your eyes get sandy, scratchy, gritty or dry?

Yes No

Have you had glare/halos affect your vision?

Yes No

Have you experienced any Flashes of Light in your vision recently?

Yes No

Regarding your eyes, do you have/had any injuries, infections, surgeries, diseases, lazy eye or other eye problem?

none Itching Burning, Stinging Eye Surgery Flashes Of Light Floaters was told "might have glaucoma" Glaucoma Cataracts Cataract surgery Strabismus/no surgery Strabismus surgery "Lazy eye" (Amblyopia) Corneal ulcer Recurrent infections LASIK RK PRK Macula degeneration Diabetic Retinopathy/monitoring Diabetic retinopathy/laser trmt foreign body history Eye injury w/ vision loss Eye injury w/o vision loss Retinal problem/unknown dx keratoconus Corneal dystrophy Stye

Please list all major Injuries, Surgeries, Hospitalizations you have had:

None past pregnancy car accident surgery

Does Anyone In Your Family Have/Had Glaucoma, Retinal Detachment, Macula degeneration, Crossed/Lazy eyes, Blindness, Cataracts, Other eye diseases

none Mother Father No Siblings Brother Sister Grandparents Aunt Uncle Cousin Step Sister Step Brother Relative Diabetes Cataracts Glaucoma Retinal Detachment Macula Degeneration Crossed Eyes/Lazy Eyes Diabetic Retinopathy Blindness Other Eye Disease High Myopia High Astigmatism

Does anyone in your family have/had Diabetes, High Blood Pressure, Heart Disease, Cancer, Athritis, Lupus, Kidney Disease, Thyroid, Other

None Unsure Spouse Mother Father Siblings Brother Sister Aunt Uncle Maternal grandparents Paternal Grandparents Adopted Diabetes HBP Cancer Cardiovascular Disease Kidney Disease Lupus COPD Thyroid Arthritis Cholesterol Heart Attack Stroke Fibromyalgia Cancer

Please list all Medicines/Vitamins that you currently take:

Are you using any eyedrops? If so please list.

None Artificial Tears rewetting drops Alaway Patanol Zaditor Elestat Xalatan Lumigan Travatan Alphagan timolol Timoptic XE Ciloxan Vigamox Zymar Besifloxacin Pred Forte Lotemax Alrex Systane Blink Refresh Genteal Theratears Visine Acular

Please list all Medical/Drug Allergies you have had:

Do you use tobacco products?

No Yes

If yes, type/amount/how long?

None Cigaretts Chewing Tobacco Cigars

Do you drink alcohol?

No Yes Occasionally Socially

If yes, type/amount/how long?

None Beer Wine Hard Liquor

Do you use recreational drugs?

No Yes

If yes, type/amount/how long?

Have you ever been exposed to or infected with HIV, Hepatitis, Gonorrhea, Syphilis, Herpes? If so please list.

None HIV Herpes Hepatitis Syphilis Gonorrhea

Our Doctor routinely performs dialated eye exams to allow evaluation of the internal health of your eyes. Doing this may cause blurred vision and sensitivity to light for several hours.

Please dialate my eyes today Please reschedule my dialation I will decline dialation all together

GENERAL: Fever, weight loss, weight gain, fatigue?

None Negative

EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat

None Allergies Sinus Problems Chronic Cough Dry Throat / Mouth Hard of Hearing

CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease

None High BP Surgery Vascular Disease High Cholestrol

RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD, Apnea

None Asthma Bronchitis Emphysema COPD Sleep Apnea

GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination

None painful urination frequent urination impotence jaundice kidney stones incontinence bladder infection

MUSCLES, BONES, JOINTS: Athritis, Joint Pains, Head or Neck Injury

None joint pain stiffness swelling cramps arthritis

SKIN: growths, rashes, acne, Rosacea

None pimples, warts growths rash acne melanoma rosacea

NEUROLOGICAL: Headaches, migraines, seizures

None numbness, paralysis headache seizures migraines head trauma

PSYCHIATRIC: Depression, Anxiety, Insomnia

None anxiety depression insomnia schizophrenia Bipolar Alzheimer's

ENDORCRINE: Thyroid, Diabetes

None diabetes hypothyroid hyperthoyroid Diabetes Type I Diabetes Type II

BLOOD/LYMPH: Anemia, cholesterol, bleeding problems

None bleeding anemia high cholesterol

ALLERGIC / IMMUNOLOGIC: Rheumatoid, AIDS, Allergy Shots, Lupus

None sneezing swelling redness itching hives lupus Seasonal allergies

GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

None Diarrhea Constipation Ulcer Acid Reflux

Any other relevant information?

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