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:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
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. Kenyon, Anderson Dr. Jared, Ivie	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 AARP Advantra Freedom Aetna Altius Health Administrators AMERIBEN SOLUTION Assurant Health Bankers Life and Casualty Blue Cross of Idaho Brokers National Life Assurance Co. Carpenters Health and Security Plan CIGNA HEALTHCARE COMMISSION FOR THE BLIND Connecticut General Life Insurance Company Coupon DELTA VISION PLAN DESERET MUTUAL EDUCATORS MUTUAL INSURANCE CO EIGHTH DISTRICT ELECTRICAL BENEFIT FUND EYEMED VISIONCARE FIRST HEALTH ADMINISTRATORS First Health Network G E H A Great West Healthcare Health Claims Service Highmark Blue Cross Humana Claims I B E W ID MEDICAID ID MEDICARE Idaho Physicians Network Idaho Pipe Trades Health and Welfare Trust IDAHO STATE INS FUND Insurance Center JAS, INC Logistics Health Insurance MAIL HANDLERS BENEFIT PLAN MEDIPLUS MERITAIN HEALTH Met Life MUTUAL OF OMAHA Noridian Administrative Services North Dakota Vision Services Northwest sheet metal workers Optum Health Vision Claims Department OXFORD LIFE INSURANCE COMPANY PACIFICSOURCE HLT Postmaster Benefit Plan Prompt pay saving plan Regence Blue Shield of Idaho RRW Medicare SecureHorizons Select Care Smith Administrators STATE FARM INSURANCE Superior Vision Services Tall Tree Administrators TRICARE West Region UCT UMR UNITED HEALTH CARE United Healthcare Vision University Health Care UP RAIL EMP HLTH USAA UT - ID TEAMSTERS SECURITY Vision Care Direct Vision Service Plan VSP Sig WA-ID CARPENTERS TRUST WA-ID OPERATING ENGINEERS
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:	None AARP Advantra Freedom Aetna Altius Health Administrators AMERIBEN SOLUTION Assurant Health Bankers Life and Casualty Blue Cross of Idaho Brokers National Life Assurance Co. Carpenters Health and Security Plan CIGNA HEALTHCARE COMMISSION FOR THE BLIND Connecticut General Life Insurance Company Coupon DELTA VISION PLAN DESERET MUTUAL EDUCATORS MUTUAL INSURANCE CO EIGHTH DISTRICT ELECTRICAL BENEFIT FUND EYEMED VISIONCARE FIRST HEALTH ADMINISTRATORS First Health Network G E H A Great West Healthcare Health Claims Service Highmark Blue Cross Humana Claims I B E W ID MEDICAID ID MEDICARE Idaho Physicians Network Idaho Pipe Trades Health and Welfare Trust IDAHO STATE INS FUND Insurance Center JAS, INC Logistics Health Insurance MAIL HANDLERS BENEFIT PLAN MEDIPLUS MERITAIN HEALTH Met Life MUTUAL OF OMAHA Noridian Administrative Services North Dakota Vision Services Northwest sheet metal workers Optum Health Vision Claims Department OXFORD LIFE INSURANCE COMPANY PACIFICSOURCE HLT Postmaster Benefit Plan Prompt pay saving plan Regence Blue Shield of Idaho RRW Medicare SecureHorizons Select Care Smith Administrators STATE FARM INSURANCE Superior Vision Services Tall Tree Administrators TRICARE West Region UCT UMR UNITED HEALTH CARE United Healthcare Vision University Health Care UP RAIL EMP HLTH USAA UT - ID TEAMSTERS SECURITY Vision Care Direct Vision Service Plan VSP Sig WA-ID CARPENTERS TRUST WA-ID OPERATING ENGINEERS
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:	None AARP Advantra Freedom Aetna Altius Health Administrators AMERIBEN SOLUTION Assurant Health Bankers Life and Casualty Blue Cross of Idaho Brokers National Life Assurance Co. Carpenters Health and Security Plan CIGNA HEALTHCARE COMMISSION FOR THE BLIND Connecticut General Life Insurance Company Coupon DELTA VISION PLAN DESERET MUTUAL EDUCATORS MUTUAL INSURANCE CO EIGHTH DISTRICT ELECTRICAL BENEFIT FUND EYEMED VISIONCARE FIRST HEALTH ADMINISTRATORS First Health Network G E H A Great West Healthcare Health Claims Service Highmark Blue Cross Humana Claims I B E W ID MEDICAID ID MEDICARE Idaho Physicians Network Idaho Pipe Trades Health and Welfare Trust IDAHO STATE INS FUND Insurance Center JAS, INC Logistics Health Insurance MAIL HANDLERS BENEFIT PLAN MEDIPLUS MERITAIN HEALTH Met Life MUTUAL OF OMAHA Noridian Administrative Services North Dakota Vision Services Northwest sheet metal workers Optum Health Vision Claims Department OXFORD LIFE INSURANCE COMPANY PACIFICSOURCE HLT Postmaster Benefit Plan Prompt pay saving plan Regence Blue Shield of Idaho RRW Medicare SecureHorizons Select Care Smith Administrators STATE FARM INSURANCE Superior Vision Services Tall Tree Administrators TRICARE West Region UCT UMR UNITED HEALTH CARE United Healthcare Vision University Health Care UP RAIL EMP HLTH USAA UT - ID TEAMSTERS SECURITY Vision Care Direct Vision Service Plan VSP Sig WA-ID CARPENTERS TRUST WA-ID OPERATING ENGINEERS
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

Welcome to Our Office-Please fill out all applicable fields


VISUAL HISTORY:
Briefly describe the main reason for having an examination today:


Associated: Do you have any other symptoms related to this?


I currently wear glasses:   Full-time    Part-time  

If part-time, how often/when? Occasionally Driving Reading / Computer After contact lens removal 1-2 times per week Half time Sports Weekends Social activities  

I currently wear contacts:   Full-time    Part-time             Soft     Rigid Gas Permeable

If part-time, how often/when? Occasionally Driving 1-2 times per week Half time Sports Weekends Social activities       



Contact Lens Wearers:

Current Brand:  Acuvue 1-day Acuvue 1-day Moist Acuvue 1-day Trueye Acuvue 2 Acuvue Oasys Acuvue Oasys for Astigmatism Acuvue Oasys for Presbyopia Acuvue Advance Acuvue Advance for Astigmatism Air Optix Air Optix Night & Day Air Optix Astigmatism Air Optix Multifocal Avaira Biomedic Toric Biomedic XC Biofinity Biofinity Toric Biofinity Multifocal Clearsight 1 day Clearsight 1 day Toric Focus Dailies Standard Focus Dailies AC plus Focus Dailies Toric Frequency 55 Frequency 55 Toric Frequency 55 Aspheric Freshlook colorblends Proclear Proclear 1 day Proclear EP Proclear Multifocal Purevision Purevision 2 Purevision 2 Toric Purevision Multifocal Soflens 38 Soflens Toric Soflens Daily Disposable Soflens Multifocal Vertex Toric Boston EO Boston ES Boston XO Fluoroperm 60 Menicon Z Thin RGP - unknown material       Are your lenses comfortable?  Yes    No   
 
How old is your current pair? new 1-2 weeks 2-4 weeks very old       What is your replacement schedule?     Daily Weekly Every 2 weeks Monthly If they feel bad Quarterly Yearly      What solution do you use?    None Optifree Replenish Optifree Pure Moist Optifree Express Renu Biotrue Clear Care Kirkland Signature Revitalens Generic store brand Boston Advance Boston original Optimum B & L Gas Perm Unique Ph



Please list all eyedrops you use (OTC and Rx):            How often used?: daily occasionally rarely


Do you have a history of any of the following?                   Are you currently experiencing any of the following?
 
                                      YES NO                                                                    YES  NO                                                     YES NO
                    Blindness                                                       Headaches                                               Eyes itch    

Eye Turn (Strabismus)                                                   Blurred Vision                                             Eyes burn       

Lazy Eye (Amblyopia)                                                   Double Vision                                              Eyes tear    

              Keratoconus                                          Eyes "hurt" or "tired"                                         Eyes feel dry    

                  Glaucoma                                             Halos around lights                            Eyes feel sandy/gritty     

                   Cataracts                                Bothered by light / sun light                                        Flashing lights    

Macular Degeneration                                                   Frequent styes                                                Floaters    

     Retinal Detachment                                           Eyes frequently red        


List any eye surgeries:                                                    Other eye disease or condition                                     Describe any eye injuries: 
                                                           
 
How many hours a day do you use a computer?       Describe any visual symptoms from computer use:    
<2 hours 2 - 4 hours 5 - 8 hours 9 - 12 hours 12+ hours                                                        none Eye strain Blurred vision Headache Dry eyes Watery Itch Burn Double vision

 ____________________________________________________________________________________________________________________________________________________________

MEDICAL HISTORY / REVIEW OF SYSTEMS: 
 
Physician's Name:       Last Visit Date:   

List all medications you are currently taking (including any OTC/vitamins):                    List any medications you are allergic to: 
                       

 
Are you pregnant or nursing? Yes    No              If yes, what is the due/birth date?   

Do you have, or ever had, any CHRONIC problems in the following areas? 

                            YES  NO                                               YES  NO                           YES NO
            Migraines                     High blood pressure                   Arthritis     
  
Multiple Sclerosis                       Allergies/Hay fever                    Stroke      

             Diabetes                                         Asthma                   Anemia      

Thyroid problems                                  Emphysema                    Cancer         
   

Notes:

______________________________________________________________________________________________________________________________________________________

FAMILY HISTORY

Family history is unknown/adopted

Any history of the following in any family members (parents, grandparents, siblings, children)? 

                                            YES No    RELATIONSHIP TO PATIENT                                             YES NO    RELATIONSHIP TO PATIENT     
                        Poor Vision          Mother Father Sister Brother Aunt Uncle Grandmother Grandfather                                                       Cancer              Mother Father Sister Brother Aunt Uncle Grandmother Grandfather  
  
                             Blindness          Mother Father Sister Brother Aunt Uncle Grandmother Grandfather                                                     Diabetes             Mother Father Sister Brother Aunt Uncle Grandmother Grandfather       

          Eye turn (Strabismus)         Mother Father Sister Brother Aunt Uncle Grandmother Grandfather                                         h Blood Pressure            Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
  
        Lazy Eye (Amblyopia)           Mother Father Sister Brother Aunt Uncle Grandmother Grandfather                                                        Stroke            Mother Father Sister Brother Aunt Uncle Grandmother Grandfather

                          Glaucoma            Mother Father Sister Brother Aunt Uncle Grandmother Grandfather                                          Thyroid Disease             Mother Father Sister Brother Aunt Uncle Grandmother Grandfather   
               
                           Cataracts            Mother Father Sister Brother Aunt Uncle Grandmother Grandfather                                        Inherited Disease             Mother Father Sister Brother Aunt Uncle Grandmother Grandfather 
                                                                                                
         Macular Degeneration           Mother Father Sister Brother Aunt Uncle Grandmother Grandfather                                             what disease?    

Retinal Detachment/Disease            Mother Father Sister Brother Aunt Uncle Grandmother Grandfather

______________________________________________________________________________________________________________________________________________________

SOCIAL HISTORY (confidential)

How often do you smoke/use tobacco products?   Never Occasionally Daily
 
How often do you consume alcohol?     Never Occasionally Daily        

Do you have? HIV    Hepatitis   STDs

______________________________________________________________________________________________________________________________________________________ 

Who referred you to our office?     

If not referred, how did you hear about Family Vision Associates?    Family member Insurance list Coworker Friend Primary Care Doctor Internet Walk by

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