New Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Primary Doctor Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Primary

Insurance Information
Insurance Name:
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:
Employer/School:

Secondary

Insurance Information
Insurance Name:
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:
Employer/School:

Tertiary

Insurance Information
Insurance Name:
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:
Employer/School:

Medical History

Medical History

What eye problems are you having?
Are there any other eye issues we should know about?
Tell us about any past eye Injuries, Infections, Surgeries, Diseases
What (if any) Eye Medications are you using?
When was your Last Eye Exam?
Who was your last eye doctor?
Are there any of the following eye conditions in your family? If yes, who has them?
Glaucoma: Cataracts: Macular Degen: Retinal Detach: Crossed / Lazy:
What is your Primary Vision Correction (glasses, contacts, nothing)? If contact lenses are your main vision correction, Do you have Back up glasses?
Planning to get new glasses?
Type of CLs worn in past: Wear Time: Cleaner: Disposal:
NOTES:
Preferred Language: Race:
Please tell us of any medical conditions you have: HAs, Arthritis, Asthma, Diabetes, HBP, Heart, Infl. Bowel Dz, Seizures, Thyroid
Additional medical condition #2 Additional medical condition #3 Additional medical condition #4 Additional medical condition #5 Additional medical condition #6
Please tell us about any past Injuries, Surgeries, or Hospitalization you have had
Are You Pregnant Or Nursing: Have you had a Recent Tetanus Shot:
Notes:
Who is your Primary Care Physcian: When was your last physical exam? What was the Reason For the Visit?



What Systemic Medications are you taking? Medication #2 Medication #3 Medication #4 Medication #5 Medication #6

Please list any medications you are allergic to:
BC: OTC:
Vitamins:
FAMILY MEDICAL HISTORY: Diabetes, HBP, Heart Dz, Cancer, Athritis, Lupus, Kidney, Thyroid, Other
History 1 History 2 History 3 History 4
Occupation: Hobbies:
Tobacco: Type: How Long:
Alcohol: Type: How Long:
GENERAL: Fever, weight loss, weight gain, fatigue?
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence
MUSCLES, BONES, JOINTS: Athritis, Joint Pains, Head or Neck Injury
SKIN: growths, rashes, acne
NEUROLOGICAL: Headaches, migraines, seizures
PSYCHIATRIC: Depression, Anxiety, Insomnia
ENDORCRINE: Thyroid, Diabetes
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

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