New Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Cell Phone: Other Phone:
Email Preferred Contact Method:
Last 4 of SSN
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Vision Insurance

Insurance Information
Insurance Name:
Insurance ID:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
Last 4 of SSN:
Employer/School:

Medical Insurance

Insurance Information
Insurance Name:
Insurance ID:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
Last 4 of SSN:
Employer/School:

Medical History

CHIEF COMPLAINT

How often are your eyes burning, red, watery, or tired?
How often do your eyes itch?
Eye Meds:
Last Eye Exam:
Doctor:
REVIEW OF OCULAR SYSTEM: Injuries, Infections, Surgeries, Diseases


Family Eye History     

Glaucoma Hx:
Retinal Detach:
Crossed / Lazy:
Corneal disease/transplant
Eye cancer
Cataracts:
Macular Degen:


Demographics

Gender
Race
Preferred Language
Ethnicity

Medical History     

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

Medical History
Medical History 2
Medical History 3
Medical History 4
Medical History5
Pregnant Or Nursing:
Injuries, Surgeries, Hospitalization
Primary Care Physician:
Practice
Last Visit:
Endocrinologist/Rheumatologist/Other Specialists
No Meds
Systemic Meds:
Systemic Meds 2:
Systemic Meds 3:
Systemic Meds 4:
Over The Counter:
Vitamins:
No Known Drug Allergies
Smoking Status
Type:
How Long:


Review of Systems

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
PSYCHIATRIC: Depression, Anxiety, Insomnia

Endocrine: Diabetes, Thyroid (1131) A1C
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
IMMUNOLOGIC: Rheumatoid, AIDS, Lupus
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

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