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



CHIEF COMPLAINT: 

Pref Language:   Race:   Ethnicity:   

Height (feet)   Height (inches)    Weight 

Last Eye Exam:   Last Eye Doctor: 

I currently wear glasses: Full-time  Part-time

Interested in LVC?       Yes  No
Interested in Contacts? Yes  No
I currently wear contacts: Full-time  Part-timeRigid Gas Permeable  Soft

Are your lenses comfortable? Yes  No  Current Brand: 

CL Solution:   How old is your current pair? 

All eyedrops used:   Last used? 

List any eye injuries/surgeries:    Other   Computer Use? 

Occupation:    Hobbies: 

Smoking Status: 

PERSONAL HISTORY   Do you have any of the following?
YES NO YES NO
Glaucoma   Diabetes  
Cataracts   High Blood Pressure  
Macular Degeneration   Stroke  
Eye Turn   Thyroid  
Lazy Eye  Cancer 
Retinal Detachment High Cholesterol 


Alcohol?   How Long: 

MEDS:   OTC/Vitamins:    NKDA

 Family history is unknown/adopted.

 

FAMILY HISTORY  Does anyone in your family have the following? 

Disease/Condition

Yes

No

Glaucoma

Cataracts

Macular Degeneration

Eye turn

Lazy Eye

Retinal Detachment

Diabetes

High Blood Pressure

Stroke

Thyroid Disease

Cancer

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
ENDORCRINE: Thyroid, Diabetes
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

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