New Patient Form

Demographics

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

CityStateZipCode
Home Phone:
Work Phone:

Primary Insurance

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:
SSN:
Employer/School:

Secondary Insurance

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:
SSN:
Employer/School:

Tertiary Insurance

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:
SSN:
Employer/School:

Reason For Visit


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Reason For Visit
Comments

Location:
OD / Right
OS / Left
OU / Both
Around eye
Behind eye
Inside eyeball
Eyelid
Upper
Lower
Nasal
Temporal
Frontal
Occipital
Onset:
Upon awakening this AM
1 day
2-3 days
>3 days
>1 week
>1 month
>3 months
>1 year
Severity:
Mild
Moderate
Severe
Quality:
Dull
Sharp
Constant
Throbbing
Timing:
Constant
Intermittent
Seasonal
AM
PM
Associated:
w/driving
w/computer use
w/CL wear
Modifying:
worse in sunlight
worse at night
worse w/blink
worse upon awakening
medication helps
glasses help
artificial tears help




















PATIENT OCULAR HISTORY

Injuries, Infections, Surgeries, Diseases
Eye Meds: Last Eye Exam: Doctor:


FAMILY OCULAR HISTORY

Glaucoma: Macular Degen: Retinal Detach: Crossed/Lazy:

PRESENT VISION CORRECTION

Primary Vision Correction: Sun Rx? Planning on getting new glasses?

Medical History


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PATIENT MEDICAL HISTORY

Patient History:

Surgeries, serious injuries, hospitalizations:
Rheumatologist Endocrinologist Cardiologist

Primary Care Provider:
Approximate Weight:Lbs.
Height:Ft. In.
Hypertension: FBG: HbA1c:

Drug Allergies:No known drug allergies
Systemic MedsNo current medications
OTC / vitamins
Notes:

FAMILY MEDICAL HISTORY

Diabetes, HBP, heart Dz, cancer, arthritis, Lupus, migraines, etc.

Occupation: Hobbies:

Smoking Status Discussed Cessation
Alcohol IV Drugs

Race Ethnicity
Preferred Language

Review of Systems


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Do you currently have any of these conditions?

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, Sleep apnea
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination,
MUSCLES, BONES, JOINTS: Arthritis, Joint Pain, Gout, Head or Neck Injury
SKIN: growths, rashes, acne
NEUROLOGICAL: Headaches, MS, migraines, seizures
PSYCHIATRIC: Depression, Anxiety, Insomnia
ENDOCRINE: Thyroid, Diabetes
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Lupus
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

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