New Patient Form
Demographics
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Rev.
Fr.
Miss
Address:
City:
State/ZipCode
WI
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
TX
UT
VT
VI
VA
WA
WV
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. Winter, Christopher
Misc/Guardian
Billing Information
Is The Billing Address the Same?
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Fr.
Miss
Address
City
State
ZipCode
WI
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
TX
UT
VT
VI
VA
WA
WV
WY
Home Phone:
Work Phone:
Vision Insurance
Insurance Information
Insurance Name:
None
A-C Retirees Voluntary Benefits Plan
AARP Healthcare Options
Advantra Freedom
Aetna
AMA Insurance Agency, Inc
American Family Insurance
American Republic Insurance Company
Americare
Anthem
Associated Bag / O B A Midwest
Bankers Life
Benefit Administrative Systems, LLC
Blue Cross Blue Shield
Blue Cross Blue Shield of Illinois
Cigna Health Care
Claim Management Services
Conneticut General
Conseco Health Insurance Company
Constitution Life
Construction Workers
Continental General
DMERC B/Administar Federal
EBC
Electrical Construction Industries
Eyecare of Wisconsin
EyeMed Vision Care
farmers insurance group
Golden Rule Insurance Co
Great West Health Care
HCN
HIRSP
Humana Gold Choice/ECOW
Humana Lexington
Iron Workers Welfare Fund
Lumenos
MBA/Auxiant
Medicare
Medicare Complete
Milwaukee Carpenters
milwaukee painters local 781
Mutual Of Omaha Companies
N.V.A.
None - no insurance coverage
Operating Engineers SELF SUBMITS
Optum Health
Other
PBA
Pekin Life Insurance Company
Pennsylvania Life Co
Physicians Mutual
Physicians Plus
Plumbers local 75 health fund
Principal Life Insurance
Pyramid Life Insurance
Quad/Med
Railroad Retirement Board
Secure Horizons
Sentry Life
SISCO-Self Insured Services Company
Starmark
State Farm
Superior Vision Services
Thrivent Financial for Lutherns
Trilogy Health Insurance
Trustmark PATIENT SUBMITS
UHC Medicare Complete
UMR
Union Bankers Insurance Co.
United American Insurance Co
United Health Care
United Teachers Associates
United Wisconsin Insurance Company
Village of Sussex
Vision Benefits Of America
Vision Care Direct
Vision Insurance Plan Of America
Vision Service Plan
Visioncare Plan
Wausau
WEA
Wisc. Pipe Trades Health Fund
Wisconsin Laborer's Health Fund
Wisconsin Mason's Health Fund
Wisconsin Sheet Metal
Wisconsin UFCW Unions &Employers
Workmans Comp
WPPN/MULTIPLAN
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 Insurance
Insurance Information
Insurance Name:
None
A-C Retirees Voluntary Benefits Plan
AARP Healthcare Options
Advantra Freedom
Aetna
AMA Insurance Agency, Inc
American Family Insurance
American Republic Insurance Company
Americare
Anthem
Associated Bag / O B A Midwest
Bankers Life
Benefit Administrative Systems, LLC
Blue Cross Blue Shield
Blue Cross Blue Shield of Illinois
Cigna Health Care
Claim Management Services
Conneticut General
Conseco Health Insurance Company
Constitution Life
Construction Workers
Continental General
DMERC B/Administar Federal
EBC
Electrical Construction Industries
Eyecare of Wisconsin
EyeMed Vision Care
farmers insurance group
Golden Rule Insurance Co
Great West Health Care
HCN
HIRSP
Humana Gold Choice/ECOW
Humana Lexington
Iron Workers Welfare Fund
Lumenos
MBA/Auxiant
Medicare
Medicare Complete
Milwaukee Carpenters
milwaukee painters local 781
Mutual Of Omaha Companies
N.V.A.
None - no insurance coverage
Operating Engineers SELF SUBMITS
Optum Health
Other
PBA
Pekin Life Insurance Company
Pennsylvania Life Co
Physicians Mutual
Physicians Plus
Plumbers local 75 health fund
Principal Life Insurance
Pyramid Life Insurance
Quad/Med
Railroad Retirement Board
Secure Horizons
Sentry Life
SISCO-Self Insured Services Company
Starmark
State Farm
Superior Vision Services
Thrivent Financial for Lutherns
Trilogy Health Insurance
Trustmark PATIENT SUBMITS
UHC Medicare Complete
UMR
Union Bankers Insurance Co.
United American Insurance Co
United Health Care
United Teachers Associates
United Wisconsin Insurance Company
Village of Sussex
Vision Benefits Of America
Vision Care Direct
Vision Insurance Plan Of America
Vision Service Plan
Visioncare Plan
Wausau
WEA
Wisc. Pipe Trades Health Fund
Wisconsin Laborer's Health Fund
Wisconsin Mason's Health Fund
Wisconsin Sheet Metal
Wisconsin UFCW Unions &Employers
Workmans Comp
WPPN/MULTIPLAN
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:
Other Vision or Medical Insurance
Please list any secondary vision coverage or supplimental medical coverage
Insurance Name:
None
A-C Retirees Voluntary Benefits Plan
AARP Healthcare Options
Advantra Freedom
Aetna
AMA Insurance Agency, Inc
American Family Insurance
American Republic Insurance Company
Americare
Anthem
Associated Bag / O B A Midwest
Bankers Life
Benefit Administrative Systems, LLC
Blue Cross Blue Shield
Blue Cross Blue Shield of Illinois
Cigna Health Care
Claim Management Services
Conneticut General
Conseco Health Insurance Company
Constitution Life
Construction Workers
Continental General
DMERC B/Administar Federal
EBC
Electrical Construction Industries
Eyecare of Wisconsin
EyeMed Vision Care
farmers insurance group
Golden Rule Insurance Co
Great West Health Care
HCN
HIRSP
Humana Gold Choice/ECOW
Humana Lexington
Iron Workers Welfare Fund
Lumenos
MBA/Auxiant
Medicare
Medicare Complete
Milwaukee Carpenters
milwaukee painters local 781
Mutual Of Omaha Companies
N.V.A.
None - no insurance coverage
Operating Engineers SELF SUBMITS
Optum Health
Other
PBA
Pekin Life Insurance Company
Pennsylvania Life Co
Physicians Mutual
Physicians Plus
Plumbers local 75 health fund
Principal Life Insurance
Pyramid Life Insurance
Quad/Med
Railroad Retirement Board
Secure Horizons
Sentry Life
SISCO-Self Insured Services Company
Starmark
State Farm
Superior Vision Services
Thrivent Financial for Lutherns
Trilogy Health Insurance
Trustmark PATIENT SUBMITS
UHC Medicare Complete
UMR
Union Bankers Insurance Co.
United American Insurance Co
United Health Care
United Teachers Associates
United Wisconsin Insurance Company
Village of Sussex
Vision Benefits Of America
Vision Care Direct
Vision Insurance Plan Of America
Vision Service Plan
Visioncare Plan
Wausau
WEA
Wisc. Pipe Trades Health Fund
Wisconsin Laborer's Health Fund
Wisconsin Mason's Health Fund
Wisconsin Sheet Metal
Wisconsin UFCW Unions &Employers
Workmans Comp
WPPN/MULTIPLAN
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:
Chief Complaint
Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!
Chief Complaints
Reason For Visit:
Blurred Vision
no vision complaints
Eye Pain
blurry vision dist + near
Eye Injury
Vision Distortion
Red Eye
Loss of Vision
Eyes Itch
Burning
Eyes Water
Headaches
Floaters
Flashes
Glasses Broken
Glasses Lost
Other
Exam Type:
Comp EST
Comp NEW
Contact Lens Exam - Est
Contact Lens EX - New
Diabetic
Medical Exam
Glaucoma Work Up
Cataract Check
Post OP Cataract
Post Op Lasik/PRK
Dilation
CL Follow Up
CL Fitting
CL Dispensing Class
Other
Patient Status:
new patient
previous pt 2013
previous pt 2012
previous pt 2011
previous pt 2010
previous pt 2009
previous pt 2008
previous pt 2007
previous pt 2006
previous pt 2005
previous pt 2004
previous pt 10+ yrs
Other
Last Eye Exam:
1 year
2 years
never
3 years
5 years
10+ years
Other
Other Complaints / Notes:
Patient Past Ocular History
Eye Infections, Diseases, Injuries, Surgeries:
None
Amblyopia / Lazy Eye
Cataract Surgery
Cataracts
Eye Muscle Surgery
Floaters
Glaucoma
Lasik / Refractive Surgery
Macular Degeneration
Scratched Eye
OD
OS
OU
Other
Eye Related Medical Conditions:
None
Diabetes
Glaucoma
Macular Degeneration
Use of High Risk Meds.
Other
Eye Meds/Drops Currently Used:
None
Alphagan
Artificial Tears
Elestat
Latanoprost
Lotemax
Lumigan
Patanol
Pred Forte
Restasis
rewetting drops
Timolol 2.5%
Travatan - Z
Visine
Preservision Tabs
Eye Formula Vitamins
Other
Primary Vision Correction
Primary Vision Correction Used:
Glasses
None
SCL's disp
SCL's disp multifocal
SCL's disp monovision
SV Dist
SV Reading
Comp Rx
Other
Used:
-
Full Time
Occasional
Reading Only
Dist Only
Rarely / Never
Other
Age of Current Glasses:
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
5+ yrs
10+ yrs
Other
Planning to get new glasses?
Yes
No
if new rx
unsure
Other
Type of CLs worn:
None
Disposable Soft
RGP
Conventional
Multifocal
Monovision
Other
Wearing CL's:
8 - 10 Hours
All day
Extended
Occ. Overnight
1 day/week or less
part time
50%
Full Time
EW 6 in 1out
Other
Lens Care Solution:
Optifree
Clear Care
Boston
Renu
generic all in one
unknown
Other
Replace Contact Lenses How Often?:
daily
2 weeks
monthly
weekly
yearly
Other
Extended Wear Use? :
denies
admits
rarely
Other
Extended Wear Compliance:
Good
Fair
Poor
Other
Overall CL Compliance:
Good
Fair
Poor
Horrible
Other
NOTES:
Patient Information
Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!
Patient Medical History
Please enter your medical history below:
Normal Health
Acid Reflux
Acne
Allergies
Anxiety
Arthritis
Asthma
Cancer
Depression
Diabetes
Elev. Cholesterol
Headaches
Heart Disease
Hypertension
Nursing
Osteoporosis
Parkinson's
Pregnant
Seizure Disorder
Thyroid Disease
Other
Normal Health
Acid Reflux
Acne
ADD
Allergies
Anxiety
Arthritis
Asthma
Cancer
Depression
Diabetes
Elev. Cholesterol
Headaches
Heart Disease
Hypertension
Nursing
Osteoporosis
Parkinson's
Pregnant
Seizure Disorder
Thyroid Disease
Other
Normal Health
Acid Reflux
Acne
Allergies
Anxiety
Arthritis
Asthma
Cancer
Depression
Diabetes
Elev. Cholesterol
Headaches
Heart Disease
Hypertension
Nursing
Osteoporosis
Parkinson's
Pregnant
Seizure Disorder
Thyroid Disease
Other
Normal Health
Acid Reflux
Acne
Allergies
Anxiety
Arthritis
Asthma
Cancer
Depression
Diabetes
Elev. Cholesterol
Headaches
Heart Disease
Hypertension
Nursing
Osteoporosis
Parkinson's
Pregnant
Seizure Disorder
Thyroid Disease
Other
Normal Health
Acid Reflux
Acne
Allergies
Anxiety
Arthritis
Asthma
Cancer
Depression
Diabetes
Elev. Cholesterol
Headaches
Heart Disease
Hypertension
Nursing
Osteoporosis
Parkinson's
Pregnant
Seizure Disorder
Thyroid Disease
Other
Normal Health
Acid Reflux
Acne
Allergies
Anxiety
Arthritis
Asthma
Cancer
Depression
Diabetes
Elev. Cholesterol
Headaches
Heart Disease
Hypertension
Nursing
Osteoporosis
Parkinson's
Pregnant
Seizure Disorder
Thyroid Disease
Other
Injuries, Surgeries, Hospitalization:
Last Physical:
1 month or less
1 - 3 months
3 - 6 months
6 - 12 months
1 - 2 years
2+ years
Other
Primary Care Physcian:
-
None
Unknown
Davis
Hughes
Bradley
Urlakis
Strickroot
Other
Notes:
Systemic Meds:
Drug Allergies:
Over The Counter / Non Rx:
Vitamins:
Family Ocular History
Glaucoma:
None
Father
Mother
Sibling
Grandparent
Distant
adopted / unknown
Other
Cataracts:
None
Father
Mother
Grandparent
Sibling
adopted / unknown
Other
Diabetes:
None
Father
Mother
Grandparent
Sibling
adopted / unknown
Other
Macular Degeneration:
None
Father
Mother
Grandparent
Sibling
adopted / unknown
Other
Retinal Detachment:
None
Parents
Siblings
Grandparent
adopted / unknown
Other
Other:
None
Father
Mother
Grandparent
Sibling
adopted / unknown
Other
Additional Notes:
None
Blindness Unknown Cause
Lazy Eye
Crossed / Wandering Eye
Keratoconus
adopted / unknown
Other
Social History
Occupation:
-
Student
Teacher
Accountant
Homemaker
Retired
Other
Visually Demanding Activities/Hobbies:
-
Art
Astronomy
Baseball
Basketball
Boating
Cooking
Crafts
Dancing
Diving
Fishing
Football
Gardening
Golf
Horseback Riding
Hunting
Models
Needlepoint
None
Painting
Photography
Piano
Reading
Roller Blading
Running
Sewing
Skiing
Soccer
Softball
Swimming
Tennis
Video Games
Woodworking
Other
Employer:
-
Quad
Kohl's
Quad Tech
Other
Referred By:
Smoking Status:
Current Smoker
Former Smoker
Never Smoker
Unknown Status
Other
Alcohol:
Denies
Occasionally
Socially
Other
Drugs/Narcotics:
-
Yes
Denies
Other
HIV ?:
No
HIV +
-
Other
Details:
Submit Data
After Completing All Forms Submit Data on Final Tab