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 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 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 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:

Medical History

What is the reason for your visit?
Do you feel your eyes are changing? (if yes, please explain)
Do you have dry eyes or allergies?
When was your last eye exam?
How did you hear about us?
Who was your last eye doctor?
Occupation / Employer:
Hobbies:
How many hours a day do you use a computer?
Preferred Language
Race
Ethnicity
Do you wear contact lenses?
If no, are you interested in contact lenses?
If yes, what type of contacts do you wear?
What brand of contacts do you wear?
How often do you replace your contacts?
What brand of solution do you use?
How long have your contacts been on your eyes?
Do you have any complaints about your current contacts?
Primary Care Physician:
Telephone #:
Fax #:
Please list any surgeries you have had:
Please list any ocular surgeries you have had
List any medications you are taking:
Are you allergic to any medications? (if yes, please list them)
No medicationsno known medical allergiesYes No
Have you ever been diagnosed with any of the following?
smoking status
discuss cessasion
Has anyone in your family ever been diagnosed with any of the following? (if so please state their relationship to you)
Cataracts Macular Degeneration GlaucomaTurned Eye High Blood PressureDiabetes
NOTES/SOCIAL HISTORY

Review of Systems

Do you use tobacco products?
Type:
Amount:
How Long?
Do you drink alcohol?
Type:
Amount:
How Long?
Do you use illegal drugs?
Type:
Amount:
How Long?
GonorrheaHepatitisHIV Syphilis
GENERAL: Fever, weight loss, weight gain, fatigue?
SKIN: growths, rashes, acne
NEUROLOGICAL: Headaches, migraines, seizures
ENDORCRINE: Thyroid, Diabetes
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux
KIDNEY, BLADDER: Kidney Stones, Frequent Urination, Pain
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus
PSYCHIATRIC: Depression, Anxiety, Insomnia
Last Dr Visit:
Reason For Visit:
Injuries, Surgeries, Hospitalization
Vitamins:
Diabetic info:
Controlled?:
Discussed Smoking Cessation

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