New Patient Form

Demographics

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

Address:
City:	State/ZipCode	TX 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 OK OH OR PA RI SC SD TN UT VT VI VA WA WV WI WY

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	Single Married Separated Divorced Widowed Unknown	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. DeFeo, Victoria Dr. Brinegar, Vaughn	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
	TX 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 OK OH OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:

Work Phone:

Insurance 1 (VISION)

Insurance Information ?

Insurance Name:	None ?? 5122501580 fax AARP Aetna Aetna-HMO Aetna Vision Discount Always Vision Ameritas Arc Mediview avesis Bankers Life & Casualty Benefit planners Blue Cross Blue Shield Blue Cross Blue Shield ppo CAre MARK Cigna CIGNA Insurance CIGNA INTERNATIONAL Cigna open access plus CNic CNIC Health Solutions Coventry Health Care eye med EyeMed EyeMed Discount Plan First Care Health Plans FirstCare SWL&H FISERV Forest north gift card Gaurdian Golden Rule golden rule - a united healthcare company Great West Group & Pension Administrators, Inc. (GPA) Group Plan Administrators Guardian Guardian-phcs MD Plan Guardian / BCBS Health Net HMO Blue Texas Humana Humana \ eyemed Humana PPO Humana Vision Care Plan I.B.E.W Local Trust Imerica Life and Health Insurance InfantSee Lumenos Medeview Medi- Plan Medicare Medicare- Private pay Mega Life and Health Insurance Company Metlife Midwest National Life Insurance Mountain States administraive Services none NRECA Cooperative Benefits outlook vision P H C s PHCS PHCS----- PHCS MD plan PHCS Assurant Health PHCS Benefit Planners PHCS CBSA PERFORMAX PHCS Destiny PHCS Fiserv PHCS Group & Pension Administrators Phcs Group Administrators PHCS Guardian Phcs Imerica PHCS NASE PHCS NCAS PHCS PacifiCare PHCS Principal Life Insurance Co Preferred Care Principal Private Pay Private Pay vsp access plan Private Pay/ Aetna Private Pay/Discount priviate pay QCD 20% off RE-Life rep Safe Guard safeguard Scott & White Scott &White Scott and White See Insurance Cards (Main Category) Seton Seton Family of Hospitals Employee Health Plan seton healthcare Seton Healthcare Network Seton Heathcare Network Spectera Spectera ????? Spectera?? Spectera???? Tesas True Choice Texas Community Care Texas True Choice the doctor TML Intergovernmental Employee Benefits Pool Tri-Care Tri Care Tricare TRS- Care/Aetna UHC UHC Allies UHC Pacificare UMR Uni-Care PPO Uni Care UniCare Unicare- EyeMed Unicare PPO unicareppo Unite Health Care United Health Care Pacificare United / Spectera United Commercial Travelers Of America United Health Care United Health Care-didn't bring card with her United Health Care Allies discount only United Health Care Vision United Health Care. United Healthcare United Healthcare (HMO) United Healthcare (spectera) unitedhealthcare Unity Health Insurance untited Health Care US Health and Life Insurance Co. VA VIsion One- Discount Vision Service Plan Vision Service Plan- Access Vision Service Plan -access Vision Service Plan Well Vision vsp Access 20 percent disc VSP Access Plan vsp sight for students
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:

Insurance 2 (MEDICAL)

Insurance Information ?

Insurance Name:	None ?? 5122501580 fax AARP Aetna Aetna-HMO Aetna Vision Discount Always Vision Ameritas Arc Mediview avesis Bankers Life & Casualty Benefit planners Blue Cross Blue Shield Blue Cross Blue Shield ppo CAre MARK Cigna CIGNA Insurance CIGNA INTERNATIONAL Cigna open access plus CNic CNIC Health Solutions Coventry Health Care eye med EyeMed EyeMed Discount Plan First Care Health Plans FirstCare SWL&H FISERV Forest north gift card Gaurdian Golden Rule golden rule - a united healthcare company Great West Group & Pension Administrators, Inc. (GPA) Group Plan Administrators Guardian Guardian-phcs MD Plan Guardian / BCBS Health Net HMO Blue Texas Humana Humana \ eyemed Humana PPO Humana Vision Care Plan I.B.E.W Local Trust Imerica Life and Health Insurance InfantSee Lumenos Medeview Medi- Plan Medicare Medicare- Private pay Mega Life and Health Insurance Company Metlife Midwest National Life Insurance Mountain States administraive Services none NRECA Cooperative Benefits outlook vision P H C s PHCS PHCS----- PHCS MD plan PHCS Assurant Health PHCS Benefit Planners PHCS CBSA PERFORMAX PHCS Destiny PHCS Fiserv PHCS Group & Pension Administrators Phcs Group Administrators PHCS Guardian Phcs Imerica PHCS NASE PHCS NCAS PHCS PacifiCare PHCS Principal Life Insurance Co Preferred Care Principal Private Pay Private Pay vsp access plan Private Pay/ Aetna Private Pay/Discount priviate pay QCD 20% off RE-Life rep Safe Guard safeguard Scott & White Scott &White Scott and White See Insurance Cards (Main Category) Seton Seton Family of Hospitals Employee Health Plan seton healthcare Seton Healthcare Network Seton Heathcare Network Spectera Spectera ????? Spectera?? Spectera???? Tesas True Choice Texas Community Care Texas True Choice the doctor TML Intergovernmental Employee Benefits Pool Tri-Care Tri Care Tricare TRS- Care/Aetna UHC UHC Allies UHC Pacificare UMR Uni-Care PPO Uni Care UniCare Unicare- EyeMed Unicare PPO unicareppo Unite Health Care United Health Care Pacificare United / Spectera United Commercial Travelers Of America United Health Care United Health Care-didn't bring card with her United Health Care Allies discount only United Health Care Vision United Health Care. United Healthcare United Healthcare (HMO) United Healthcare (spectera) unitedhealthcare Unity Health Insurance untited Health Care US Health and Life Insurance Co. VA VIsion One- Discount Vision Service Plan Vision Service Plan- Access Vision Service Plan -access Vision Service Plan Well Vision vsp Access 20 percent disc VSP Access Plan vsp sight for students
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

What is the main reason for today?s exam?

PATIENT OCULAR HISTORY:

Do your eyes sting, burn, itch, or feel dry? Do they get red or water?

Are you bothered by glare/haloes/bright light? Are your eyes tired??

Do you experience headaches around your temples or forehead??

Have you had any eye injuries or surgeries??

Have you been diagnosed with cataracts, lazy eye, retinal problems, floaters, macular degeneration, color blindness, or glaucoma??

Please write ?NONE? or list key words below to discuss with your doctor.

What eye medicines do you take, including over-the-counter?

Last Eye Exam:

Doctor/Clinic (please list City/St if outside Austin):

FAMILY OCULAR HISTORY:

Do you have a family history of any of the following?? Please list relative or type ?NO?.

Glaucoma

Age Related Macular Degeneration

Crossed/Lazy Eye

Retinal Detachment

Cataracts

Blindness

Color Blindness

Other

SPECTACLE LENS HISTORY:

Primary Vision Correction:

Have you had trouble in the past with glasses?

Are you interested in finding out if you are a candidate for LASIK?

Would you like a prescription for computer glasses?

Yes No

Do you have problems with night vision?

Do you wear sunglasses?

Yes No

Do you do yard work, woodwork, weld, or play high impact sports?

CONTACT LENS HISTORY: (SKIP TO NEXT SECTION IF NONE APPLY)

Are you interested in a contact lens prescription today?

no YES

Are you interested in color contact lenses?

Have you ever tried to wear contacts?

no yes

Reason for stopping?

Do you have glasses you can see well with if not wearing contacts?

Yes No

Current contact lens brand:

How many hours do you wear your lenses per day?

Solution:

How often do you replace your lenses?

2 weeks monthly daily weekly yearly

How often do you sleep in your lenses?

always never occasional 2-3x/wk

Rate the following on a scale of 1-10, with 1 being POOR to 10 EXCELLENT: Lens Comfort:

Vision:

PATIENT MEDICAL HISTORY:

PRIMARY CARE PHYSICIAN:

Telephone:

Last Visit:

What medicine do you take, including over-the-counter and vitamins?

med2

med3

med4

med5

med6

med7

med8

med9

med10

med11

med12

What allergies to medicine do you have (include latex)?

Do you have a history of headaches? Arthritis? Asthma? Diabetes? High Blood Pressure? Heart Problems? Inflammatory Bowel Disease? Seizures? Thyroid Problems?

medhx2

medhx3

medhx4

medhx5

medhx6

Please list major injuries, surgeries, & hospitalizations:

Females: Are you pregnant or nursing?

No Nursing Pregnant Yes Unsure

FAMILY MEDICAL HISTORY:

Does anyone in your family have: Diabetes, High Blood Pressure, Heart Disease, Cancer, Arthritis, Lupus, Kidney, Thyroid, Stroke, Other(s)?

fmh2

fmh3

fmh4

fmh5

fmh6

SOCIAL HISTORY:

Occupation:

Employer:

Hobbies:

Do you smoke?

No Yes

Type

None Cigaretts Chewing Tobacco

How much?

Do you drink alcohol?

No Yes Occasionally Socially

How often?

Illegal Drugs?

No Yes

Type

STUDENT HISTORY: PLEASE SKIP TO NEXT SECTION IF NOT APPLICABLE.

Have you noticed the following in your child?

Eye Turn?

No Yes

Eyes frequently watering?

No Yes

Eyes frequently red?

No Yes

Swelling around the eyes?

No Yes

White appearance in pupil?

No Yes

Have trouble seeing distant objects?

No Yes

Lose their place while reading?

No Yes

Avoid close work?

No Yes

Hold reading material closer than normal?

No Yes

Have difficulty copying from the chalkboard?

No Yes

Tend to rub their eyes?

No Yes

Have difficulty recognizing the same word on a different page?

No Yes

Have headaches?

No Yes

Turn or tilt head to use one eye only?

No Yes

Make frequent reversals when reading or writing?

No Yes

Use finger to maintain place while reading?

No Yes

Omit or confuse small words when reading?

No Yes

Consistently perform below potential?

No Yes

REVIEW OF SYSTEMS:

Are you currently experiencing any of the following?

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: Arthritis, Joint Pains, Head or Neck Injury

SKIN: growths, rashes, acne

NEUROLOGICAL: Headaches, migraines, seizures, multiple sclerosis

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