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
Cell Phone:
Other Phone:
Email
Preferred Contact Method:
Home Phone
Work Phone
Cell Phone
Other Phone
Text Message
Email
Last 4 of SSN
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
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:
Vision Insurance
Insurance Information
Insurance Name:
None
Aetna Vision-Eyemed Assignment
Avesis-Eyemed Assignment Plan
Davis Vision - Eyemed Assignment Plan
Eyemed
Humana Vision-My Comp Beneifts
NVA: we don't take this plan
REO
Spectera
Superior Vision
VSP
Insurance ID:
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:
Last 4 of SSN:
Employer/School:
Medical Insurance
Insurance Information
Insurance Name:
None
AARP Medicare Complete-Secure Horizons
Aetna- El Paso, TX
Aetna - Lexington, KY
AmeriBen
Anthem - Blue Cross & Blue Shield of Colorado
BC/BS - Federal
Cigna - Chattanooga
Cigna - Kennett, MO
Cigna Envoy
CNIC Health Solutions - UMR
Cofinity
Cofinity-Meritain Health
Cofinity Farmington Hills, MI
Developmental Pathways - Charity
EBMS - Aetna
Eyemed Assignment Plan
GEHA - Independence, MO
Golden Rule
Humana Claims
Kaiser-We dont take this ins
Medica
Medicaid (Colorado)
Medicare - Part B
Medicare - Railroad Retirement
Medico
Meritain Health-Aetna
Tricare West
UMR
UMR- Onalaska, WI
UMR - Valor Christian - self pay reimbursement plan
United Health Care
United Health Integrated Services
Insurance ID:
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:
Last 4 of SSN:
Employer/School:
Medical History
CHIEF COMPLAINT
How often are your eyes burning, red, watery, or tired?
Several Times Per Day
Once or Twice Per Day
2-3 Times Per Week
Rarely
Other
How often do your eyes itch?
Spring
Fall
Year round
Other
Eye Meds:
Last Eye Exam:
1 year
2 years
3 years
Other
Doctor:
Doesn't Remember
Abbas
Blount
Boyle
Broussard
Cass
Chuckweike
Conroy
DeRouen
Diaz
Doucet
EyeMart
EyeMasters
Fracht
Harmon
Hyde
Johnson
Lehman
Lens Crafters
Levacy
Maynard
Never
Pearl
Rising
Singla
Yu
Lisa Hamilton, OD
Audrey Merryman, OD
Melissa Patrlja, OD
Other
REVIEW OF OCULAR SYSTEM: Injuries, Infections, Surgeries, Diseases
No Past Ocular Problems
Itching
Burning, Stinging
Amblyopia
Eye Injuries
Eye Surgery
Flashes Of Light
Floaters
Strabismus
Cataracts
Glaucoma
Retinal Disorders
Glaucoma suspect
Other
Family Eye History
All Normal
Glaucoma Hx:
No
Adopted
Mother
Father
Brother
Sister
MGM
PGM
MGF
PGF
Other
Retinal Detach:
No
Adopted
Mother
Father
Brother
Sister
MGM
PGM
MGF
PGF
Other
Crossed / Lazy:
No
Adopted
Mother
Father
Brother
Sister
MGM
PGM
MGF
PGF
Other
Corneal disease/transplant
No
Adopted
Mother
Father
Brother
Sister
MGM
PGM
MGF
PGF
Other
Eye cancer
No
Adopted
Mother
Father
Brother
Sister
MGM
PGM
MGF
PGF
Other
Cataracts:
No
Adopted
Mother
Father
Brother
Sister
MGM
PGM
MGF
PGF
Other
Macular Degen:
No
Adopted
Mother
Father
Brother
Sister
MGM
PGM
MGF
PGF
Other
Demographics
Gender
Unknown
Male
Female
Other
Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
Other Race
Patient Declined to Specify
White
Other
Preferred Language
English
Spanish
French
Patient Declined to Specify
Abkhazian
Afar
Afrikaans
Akan
Albanian
Amharic
Arabic
Aragonese
Armenian
Assamese
Avaric
Avestan
Aymara
Azerbaijani
Bambara
Bashkir
Basque
Belarusian
Bengali
Bihari languages
Bislama
Bokm?l, Norwegian), Norwegian Bokm?l
Bosnian
Breton
Bulgarian
Burmese
Catalan; Valencian
Central Khmer
Chamorro
Chechen
Chichewa; Chewa; Nyanja
Chinese
Church Slavic; Old Slavonic; Church Slavonic; Old Bulgarian; Old Church Slavonic
Chuvash
Cornish
Corsican
Cree
Croatian
Czech
Danish
Divehi; Dhivehi; Maldivian
Dutch; Flemish
Dzongkha
Esperanto
Estonian
Ewe
Faroese
Fijian
Finnish
Fulah
Gaelic; Scottish Gaelic
Galician
Ganda
Georgian
German
Greek, Modern (1453-)
Guarani
Gujarati
Haitian; Haitian Creole
Hausa
Hebrew
Herero
Hindi
Hiri Motu
Hungarian
Icelandic
Ido
Igbo
Indonesian
Interlingua (International Auxiliary Language Association)
Interlingue; Occidental
Inuktitut
Inupiaq
Irish
Italian
Japanese
Javanese
Kalaallisut; Greenlandic
Kannada
Kanuri
Kashmiri
Kazakh
Kikuyu; Gikuyu
Kinyarwanda
Kirghiz; Kyrgyz
Komi
Kongo
Korean
Kuanyama; Kwanyama
Kurdish
Lao
Latin
Latvian
Limburgan; Limburger; Limburgish
Lingala
Lithuanian
Luba-Katanga
Luxembourgish; Letzeburgesch
Macedonian
Malagasy
Malay
Malay
Malayalam
Maltese
Manx
Maori
Maori
Marathi
Marshallese
Mongolian
Nauru
Navajo; Navaho
Ndebele, North; North Ndebele
Ndebele, South; South Ndebele
Ndonga
Nepali
Northern Sami
Norwegian
Norwegian Nynorsk; Nynorsk, Norwegian
Occitan (post 1500)
Ojibwa
Oriya
Oromo
Ossetian; Ossetic
Pali
Panjabi; Punjabi
Persian
Polish
Portuguese
Pushto; Pashto
Quechua
Romanian; Moldavian), Moldovan
Romansh
Rundi
Russian
Samoan
Sango
Sanskrit
Sardinian
Serbian
Shona
Sichuan Yi; Nuosu
Sindhi
Sinhala; Sinhalese
Slovak
Slovenian
Somali
Sotho, Southern
Sundanese
Swahili
Swati
Swedish
Tagalog
Tahitian
Tajik
Tamil
Tatar
Telugu
Thai
Tibetan
Tigrinya
Tonga (Tonga Islands)
Tsonga
Tswana
Turkish
Turkmen
Twi
Uighur; Uyghur
Ukrainian
Urdu
Uzbek
Venda
Vietnamese
Volap?k
Walloon
Welsh
Western Frisian
Wolof
Xhosa
Yiddish
Yoruba
Zhuang; Chuang
Zulu
Other
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Unknown
Patient Declined to Specify
Other
Medical History
All Normal
Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!
Medical History
Good health
Arthritis
Asthma
HBP
Headaches
Heart Condition
HX Of Drug/Alcohol Abuse
Inflammatory Bowel Disease
Smoking
Seizure Disorder
Thyroid Disease
Preg "Now"
Nursing
Diagnosed As HIV+
Restless Leg Syndrome
Cholesterol elevated
Migraines
Diabetes (Insulin)
Diabetes (oral meds)
Arthirits-Rheumatoid
Arthritis-osteo
Auto-immune
Cancer
Sjogrens
Myasthenia Gravis
Multiple Sclerosis
Grave's
Other
Medical History 2
None
Diabetes
HBP
Heart disease
Cancer
Arthritis
Lupus
Kidney
Thyroid
Back Problems
Other
Medical History 3
None
Athritis
Diabetes
HBP
Heart Disease
Cancer
Lupus
Kidney Disease
Thyroid Disease
Back Problems
Other
Medical History 4
None
Athritis
Diabetes
HBP
Heart Disease
Cancer
Lupus
Kidney Disease
Thyroid Disease
Back Problems
Other
Medical History5
None
Athritis
Diabetes
HBP
Heart Disease
Cancer
Lupus
Kidney Disease
Thyroid Disease
Back Problems
Other
Pregnant Or Nursing:
No
Yes
Unsure
Other
Injuries, Surgeries, Hospitalization
Primary Care Physician:
Practice
Unspecified
New West Family Physicians
Kaiser Perm
Other
Last Visit:
N/A
1 week
1 month
3 months
6 months
1 year
2 years
Other
Endocrinologist/Rheumatologist/Other Specialists
No Meds
Systemic Meds:
None
Glyburide
Hydrocortisone
Glucophage
Metformin
Methlyprednisolone
Prednisone
Actos
Amaryl
Humulin
Novalog
Prempro
Premarin
Synthroid
Amiodarone
Atenolol
Captopril
Clonidin
Furosamide
Lasix
HCTZ
Zestril
Altase
Cozar
Crestor
Diovan
Lipitor
Albuterol
Allegra
Flonase
Nasacort
Singular
Proventil
Pepcid
Zantac
Protonix
Detrol
Flomax
Xanax
Wellbutrin
Buspar
Valium
Prozac
Ritalin
Adderall
Effexor
Zoloft
Diclofenac
Lortab
MS Contin
Oxycodone
Celebrex
Carbamazepine
Depakote
Topamax
Dilantin
Coumadin
Plavix
Bactroban
Cipro
Acyclovir
Cefzil
Amoxycillin
Augmentin
Tetracycline
Levaquin
Plaquenil
Other
Systemic Meds 2:
None
Glyburide
Hydrocortisone
Glucophage
Metformin
Methlyprednisolone
Prednisone
Actos
Amaryl
Humulin
Novalog
Prempro
Premarin
Synthroid
Amiodarone
Atenolol
Captopril
Clonidin
Furosamide
Lasix
HCTZ
Zestril
Altase
Cozar
Crestor
Diovan
Lipitor
Albuterol
Allegra
Flonase
Nasacort
Singular
Proventil
Pepcid
Zantac
Protonix
Detrol
Flomax
Xanax
Wellbutrin
Buspar
Valium
Prozac
Ritalin
Adderall
Effexor
Zoloft
Diclofenac
Lortab
MS Contin
Oxycodone
Celebrex
Carbamazepine
Depakote
Topamax
Dilantin
Coumadin
Plavix
Bactroban
Cipro
Acyclovir
Cefzil
Amoxycillin
Augmentin
Tetracycline
Levaquin
Plaquenil
Other
Systemic Meds 3:
None
Glyburide
Hydrocortisone
Glucophage
Metformin
Methlyprednisolone
Prednisone
Actos
Amaryl
Humulin
Novalog
Prempro
Premarin
Synthroid
Amiodarone
Atenolol
Captopril
Clonidin
Furosamide
Lasix
HCTZ
Zestril
Altase
Cozar
Crestor
Diovan
Lipitor
Albuterol
Allegra
Flonase
Nasacort
Singular
Proventil
Pepcid
Zantac
Protonix
Detrol
Flomax
Xanax
Wellbutrin
Buspar
Valium
Prozac
Ritalin
Adderall
Effexor
Zoloft
Diclofenac
Lortab
MS Contin
Oxycodone
Celebrex
Carbamazepine
Depakote
Topamax
Dilantin
Coumadin
Plavix
Bactroban
Cipro
Acyclovir
Cefzil
Amoxycillin
Augmentin
Tetracycline
Levaquin
Plaquenil
Other
Systemic Meds 4:
None
Glyburide
Hydrocortisone
Glucophage
Metformin
Methlyprednisolone
Prednisone
Actos
Amaryl
Humulin
Novalog
Prempro
Premarin
Synthroid
Amiodarone
Atenolol
Captopril
Clonidin
Furosamide
Lasix
HCTZ
Zestril
Altase
Cozar
Crestor
Diovan
Lipitor
Albuterol
Allegra
Flonase
Nasacort
Singular
Proventil
Pepcid
Zantac
Protonix
Detrol
Flomax
Xanax
Wellbutrin
Buspar
Valium
Prozac
Ritalin
Adderall
Effexor
Zoloft
Diclofenac
Lortab
MS Contin
Oxycodone
Celebrex
Carbamazepine
Depakote
Topamax
Dilantin
Coumadin
Plavix
Bactroban
Cipro
Acyclovir
Cefzil
Amoxycillin
Augmentin
Tetracycline
Levaquin
Plaquenil
Other
Over The Counter:
None
Asprin
Acetomenophin
Ibuprofen
Other
Vitamins:
None
A
E
C
Zinc
Xanten
Lutein
Other
No Known Drug Allergies
Smoking Status
Current every day smoker
Current some day smoker (not daily)
Former smoker (no longer smokes)
Heavy smoker (>10 cigs/day)
Light smoker (<10 cigs/day)
Never smoker (<100 cigs equiv)
Smoker (current status unknown)
Unknown if ever smoked
Other
Type:
N/A
Cigarettes
Chewing Tobacco
Cigar
Other
How Long:
Review of Systems
GENERAL: Fever, weight loss, weight gain, fatigue?
None
Weight Gain
Weight Loss
Chronic Fatigue
Other
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat
None
Allergies
Sinus Problems
Chronic Cough
Dry Throat / Mouth
Hard of Hearing
Other
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease
None
High BP
Surgery
Vascular Disease
Stints
Other
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD
None
Asthma
Bronchitis
Emphysema
COPD
Other
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence
None
painful urination
frequent urination
impotence
yellow jaundice
Other
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury
None
joint pain
stiffness
swelling
cramps
arthritis
Gout (Gouty Arthritis)
Other
SKIN: growths, rashes, acne
None
growths
rash
Eczema (dermatitis)
Skin Cancer
Acne
Other
NEUROLOGICAL: Headaches, migraines, seizures
None
numbness, paralysis
headache
seizures
migraines
multple sclerosis
Other
PSYCHIATRIC: Depression, Anxiety, Insomnia
None
anxiety
depression
insomnia
ADHD
Bi-polar
Other
Endocrine: Diabetes, Thyroid (1131)
A1C
None
Insulin Dependent Diabetes
Non-Insulin Dependent Diabetes
Hypo-Thyroid
Hyper-Thryroid
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
None
bleeding
cholestrolemia
anemia
Other
IMMUNOLOGIC: Rheumatoid, AIDS, Lupus
None
lupus
Rheumatoid Arthritis
AIDS (HIV +)
Other
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux
None
Diarrhea
Constipation
Ulcer
Acid Reflux
Other
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