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
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 Plan:
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 Information
Insurance Name:
Insurance Plan:
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 Information
Insurance Name:
Insurance Plan:
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:

Vision

Insurance Information
Insurance Name:
Insurance Plan:
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:

Vision 2

Insurance Information
Insurance Name:
Insurance Plan:
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:

ABN Variables

Insurance Information
Insurance Name:
Insurance Plan:
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 Complaints


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Chief Complaints and Patient Information
Reason for Visit:
Secondary Complaints:
Last Eye Exam:             Doctor:
Nickname
Preferred Language:
Race:             Ethnicity:

Review of Ocular System
Injuries, Infections, Surgeries, Diseases
Eye Meds:

Double Vision: Recent Onset: FarNear
Flashes: Recent Onset: Eye:
Floaters: Recent Onset: AlotFew Eye:
HA's Recent Onset

Pain: Eye: Redness: Eye:
Itchiness: Eye: Tearing: Eye:
Burning: Eye: Dryness: Eye:

Discharge: Photophobia:

Primary Vision Correction Information
Primary Vision Correction: Back up glasses? Wants new glasses?

Previous Contact Lenses Wear Time Today: Max. Wear Time:
Care System: Disposal:

Family Ocular History - Unknown family history
Cataracts: Diabetes: Glaucoma: Macular Degeneration:
Retinal Detachment: Crossed / Lazy:


Medical History


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Patient Medical History

Injuries, Surgeries, Hospitalization

Primary Care Provider Last Physical Exam: Last Visit
Reason For Visit: Pregnant Or Nursing: Recent Tetanus Shot:
Recent Flu Shot: PCP Fax PCP Phone

Systemic Meds: Drug Allergies:

Family Medical History
Diabetes, HBP, Heart Dz, Cancer, Athritis, Lupus, Kidney, Thyroid, Other:

Social History
Occupation: Hobbies: Pets:
Music: Sports: STD: Daily Computer Use

Smoking Status: Type: How Long / How Long Quit:

Alcohol: Type: How Long:/ How Long Quit
Illegal Drugs: Type: How Long:/ How Long Quit

Current Medications
No Current Medications         No known drug allergies

BC: OTC: Vitamins: Drug Allergies:


Review of Systems


Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!
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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