Welcome Form

Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev. Master Miss Other

Address:
City:		State/ZipCode	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 TX UT VT VA WA WV WI WY

Home Phone:		Work Phone:
Other Phone:		Email
SSN (optional)		Date of Birth
Sex	Male Female	Occupation
Marital Status	Single Married Separated Divorced Widowed Other Unknown	Employer/School Name	Employed Full-Time Student Part-Time Student
Date of Appointment

Billing Information

Please check if the billing address is the same as above:

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev.

Address

City	State	ZipCode
	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 TX UT VT VA WA WV WI WY

Home Phone:
Work Phone:

Ethnicity Height Weight Other White African American Asian Hispanic Indian Primary Language English Spanish Other Hobbies: Medications and the reason you take them Medication Allergies PATIENT MEDICAL HISTORY - please enter any significant medical conditions that the patient has had either now or in the past ****************************************************************************************************** Diabetics Only: Please check if you are diabetic and fill out the following: Year diagnosed I take insulin Last blood sugar readings Last A1C (if known) ****************************************************************************************************** Over-the-counter supplements Tobacco use none 1/2 ppd 1 ppd 1.5 ppd social smoker chewing Year started Pregnant Or Nursing

No Yes Unsure

Blood-related family medical problems such as diabetes or high blood pressure (please indicate the relationship, such as grandparent, parent, or sibling)

Relationship

n/a grandparent parent sibling

Review of Systems: Please indicate if you have problems with any of the following:

GENERAL: Fever, Weight loss, Weight gain, Fatigue

None Fever Weight gain Weight Loss

INTEGUMENTARY: Growths, Rashes, Acne

None Growths Rash Acne Warts

NEUROLOGICAL: Headaches, Migraines, Seizures

None Numbness, paralysis Headache Seizures Migraines Multiple sclerosis

ENDOCRINE: Thyroid, Diabetes

None Hypothyroid Hyperthyroid Diabetes

EAR, NOSE, MOUTH, THROAT: Allergies, Sinus, Cough, Dry Mouth/Throat

None Allergies Hay fever Sinus Problems Chronic Cough Dry Throat / Mouth Hard of Hearing Runny Nose Post-nasal drip

RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD

None Asthma Bronchitis Emphysema COPD

CARDIOVASCULAR: Hypertension, Heart Surgery, Vascular Disease, High Cholesterol

None Surgery Vascular Disease Hypertension Heart Disease Diabetes High Cholesterol

GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

None Diarrhea Constipation Ulcer Acid Reflux Irritable bowel syndrome

GENITOURINARY: Kidney Stones, Frequent Urination, Impotence, BPH

None Painful urination Frequent urination Impotence BPH Kidney stones

MUSCULOSKELETAL: Athritis, Joint Pain, Head or Neck Injury

None Arthritis Joint pain Muscle pain Stiffness Swelling Cramps Osteoporosis Osteopenia

HEMATOLOGIC/LYMPHATIC: Anemia, Bleeding problems

None Bleeding Anemia

ALLERGIC/IMMUNOLOGIC: Seasonal Allergies, Allergy Shots

None Sneezing Swelling Redness Itching HIV Hives Lupus Lyme Disease Sarcoidosis

PSYCHIATRIC: Depression, Anxiety, Insomnia

None Anxiety Depression Insomnia ADD ADHD Bi-polar disorder

Year of last full exam

Unknown Never 2000 or before 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Location

Age of glasses (year)

Unknown n/a 2000 or before 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

How do you wear your glasses?

n/a all the time distance only near only as needed, d and n backup for CLs

Eyedrops or ocular vitamins

Eye surgeries or injuries - please indicate which eye and dates

Past eye problems - please indicate date of onset

Family history of eye disease - please indicate relationship

Please list any medical problems you may have with your eyes, dry eye, burning, allergies, glaucoma, etc.

Please scroll to the top of the page and fill out insurance information (our office can accept most major medical insurance and vision insurance plans), and then select the SUBMIT DATA tab. You will then be done with the registration!

Primary Vision Insurance

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:
Employer/School:

Secondary Vision Insurance

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:
Employer/School:

Primary Medical Insurance

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:
Employer/School:

Secondary Medical Insurance

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:
Employer/School:

Submit Data