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 OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:		Work Phone:
Cell 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. Wademan, OD, Jennifer Dr. Van Winkle, OD, Lauren	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 OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None AAG - American Admin Group AARP Ademity Pyramid Life Advantica Eye Care Aetna Alaska Care American Benefits Management ANTHEM BLUE CROSS AVP Benefit Coordinators Corporation Benefit Planners Benelect Blue Cross of California BLUE CROSS OF NEW JERSEY Blue Shield Of California Boon-Chapman Benifite Adm. Inc. CAREMARK CHP- CONSOLIDATED HEALTH PLANS Cigna CLaims Central Coresource DAVIS VISION DELTA HEALTH SYSTEMS EBA & M EMP C/O ABM EyeMed Vision First Health Fiserv Health FMH Benefit SVS Great West Guardian Health Comp Health Net Health Partners Healthy Families Heatlh New England Humana Interplan Life Wise Lumenos Managed Benefit Administrators Medi-Cal Medicaid Medicaid/ Blue Cross Medical Eye Services Medicare Morris Associates Morrise Assosiates PHCS My CompBenefits New Insurance NGS American , Inc. Optum Health Vision Other Pacific Source Health Plans Pacificare Pequot Plus Health Benefits Services Premera Blue Cross Premier Claims Administrator Principal Financial Group Principal Life Insurance Private Pay River City Medical Safeguard Sheet Metal Workers 104 Signature Employer Resource, L.L.C. Spectera/VSP Standard Security Life Superior Vision Symetra Tantara Tricare UFCW Northern California Underwriters Unicare United Healthcare Valley Oaks Insurance VANBREDA INTERNATIONAL Vision Care Plan Vision Service Plan VSP/MEDI-CAL VSP/MES Wassau
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:	None AAG - American Admin Group AARP Ademity Pyramid Life Advantica Eye Care Aetna Alaska Care American Benefits Management ANTHEM BLUE CROSS AVP Benefit Coordinators Corporation Benefit Planners Benelect Blue Cross of California BLUE CROSS OF NEW JERSEY Blue Shield Of California Boon-Chapman Benifite Adm. Inc. CAREMARK CHP- CONSOLIDATED HEALTH PLANS Cigna CLaims Central Coresource DAVIS VISION DELTA HEALTH SYSTEMS EBA & M EMP C/O ABM EyeMed Vision First Health Fiserv Health FMH Benefit SVS Great West Guardian Health Comp Health Net Health Partners Healthy Families Heatlh New England Humana Interplan Life Wise Lumenos Managed Benefit Administrators Medi-Cal Medicaid Medicaid/ Blue Cross Medical Eye Services Medicare Morris Associates Morrise Assosiates PHCS My CompBenefits New Insurance NGS American , Inc. Optum Health Vision Other Pacific Source Health Plans Pacificare Pequot Plus Health Benefits Services Premera Blue Cross Premier Claims Administrator Principal Financial Group Principal Life Insurance Private Pay River City Medical Safeguard Sheet Metal Workers 104 Signature Employer Resource, L.L.C. Spectera/VSP Standard Security Life Superior Vision Symetra Tantara Tricare UFCW Northern California Underwriters Unicare United Healthcare Valley Oaks Insurance VANBREDA INTERNATIONAL Vision Care Plan Vision Service Plan VSP/MEDI-CAL VSP/MES Wassau
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:	None AAG - American Admin Group AARP Ademity Pyramid Life Advantica Eye Care Aetna Alaska Care American Benefits Management ANTHEM BLUE CROSS AVP Benefit Coordinators Corporation Benefit Planners Benelect Blue Cross of California BLUE CROSS OF NEW JERSEY Blue Shield Of California Boon-Chapman Benifite Adm. Inc. CAREMARK CHP- CONSOLIDATED HEALTH PLANS Cigna CLaims Central Coresource DAVIS VISION DELTA HEALTH SYSTEMS EBA & M EMP C/O ABM EyeMed Vision First Health Fiserv Health FMH Benefit SVS Great West Guardian Health Comp Health Net Health Partners Healthy Families Heatlh New England Humana Interplan Life Wise Lumenos Managed Benefit Administrators Medi-Cal Medicaid Medicaid/ Blue Cross Medical Eye Services Medicare Morris Associates Morrise Assosiates PHCS My CompBenefits New Insurance NGS American , Inc. Optum Health Vision Other Pacific Source Health Plans Pacificare Pequot Plus Health Benefits Services Premera Blue Cross Premier Claims Administrator Principal Financial Group Principal Life Insurance Private Pay River City Medical Safeguard Sheet Metal Workers 104 Signature Employer Resource, L.L.C. Spectera/VSP Standard Security Life Superior Vision Symetra Tantara Tricare UFCW Northern California Underwriters Unicare United Healthcare Valley Oaks Insurance VANBREDA INTERNATIONAL Vision Care Plan Vision Service Plan VSP/MEDI-CAL VSP/MES Wassau
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

VISION AND MEDICAL HISTORY Referred By:

Friend/Co-Worker Family Member Insurance List Roseville Style Magazine Internet Search Engine i.e. Google Walk-by/Drive-by Website/Internet Yellow Pages- book Yellow Pages- internet Yelp Other

Name of person who referred you?

Preferred Method of Contact

Text Call Email Any

Family Patients:

Occupation:

Hobbies:

Interested In Contact Lens Exam?

Yes No Maybe, discuss w/ Dr.

Ever Worn Contact Lenses?

Yes No Tried but didn't like

Type of CLs worn in past:

None 1 mo disposables 2 week disposables Daily disposables Extended Wear Disposable Multifocal Disposable Monovision - Disposables Gas Permeables Gas Perm Bifocals Monovision - Gas Perm Conventional Yearly Soft Monovision Yearly

Interested in LASIK?

Not Interested Discuss more w/ Dr. Yes

Primary Vision Correction:

None Contact Lenses Distance/General Purpose Glasses Progressive "no-line" Multifocal Glasses Reading Only Glasses Over-the-Counter Readers Computer Glasses Lined Bifocal Glasses Lined Trifocal Glasses

Rx'd Sunglasses?

Yes No

Computer glasses?

Yes No

Back up glasses for cls?

Yes No

Computer Use (hrs/day):

None 8 hrs per day 6 hrs per day 4 hrs per day 2 hrs per day >8 hrs per day Variable

Medication Allergies:

Rxn caused by medication allergy

Are you Diabetic?

No Yes, Type I Yes, Type II Boarderline

Year diagnosed?

Do you have Hypertention?

No Yes Boarderline

Year diagnosed?

Do you have Asthma?

No Yes, Mild Yes, Moderate Yes, Severe

Do you have Glaucoma?

No Yes Suspected

Do you have Cataracts?

No Yes Suspected

Do you have Macular Degeneration?

No Yes Suspected

Do you have Dry Eyes?

No Yes Sometimes

Have you ever had Diabetic Retinopathy?

No Yes

Have you ever had Hypertensive Retinopathy?

No Yes

Have you ever had a Retinal Detachment?

No Yes

History of Eye Injury?

No Yes

Describe Injury:

Date of Inj:

History of Eye Surgery?

No Yes

Describe Type of Surg:

Date of Surg:

Other Med Hx: Thyroid,Smoke,Pregnant,Nursing,HIV+

Additional Vision or Eye Health History:

Systemic Meds:

Eye Meds:

FAMILY MEDICAL HISTORY Macular Degeneration?

No Yes Unknown

If yes, relation:

Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Aunt Uncle Sibling

Glaucoma?

No Yes Unknown

If yes, relation:

Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Aunt Uncle Sibling

Cataracts?

No Yes Unknown

If yes, relation:

Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Aunt Uncle Sibling

Retinal Detachment?

No Yes Unknown

If yes, relation:

Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Aunt Uncle Sibling

Other?

Relation:

Diabetes?

No Yes Unknown

If yes, relation:

Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Aunt Uncle Sibling

High Blood Pressure?

No Yes Unknown

If yes, relation:

Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Aunt Uncle Sibling

ADDITIONAL MEDICAL HISTORY Primary Care Physician:

Last Physical Exam?

Do You Smoke?

No Yes, socially Yes, less than 1 pack per day Yes, more than 1 pack per day

Do you drink alcohol?

No Yes, socially Yes, average 1-3 drinks per week Yes, average 1 drink per day Yes, more than 1 drink per day

Additional History

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