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:

Vision Plan

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

PATIENT MEDICAL HISTORY
Please select from the following drop down lists for any conditions you might have.
Such as Arthritis, Asthma, Cancer, Diabetes, HBP, Heart, IBD, SLE, Thyroid, other

Condition
What was the date it was diagnosed? (MM/YYYY)
1)
2)
3)
4)
5)

 

 

 


 

 

Please enter any conditions you have, not found on the list.

What was the date it was diagnosed? (MM/YYYY)

Please list any injuries, surgeries, or history hospitalization:
Please list all medications you currently take:
Are you currently pregnant or nursing?

Please provide the name of your primary care physician.
What was the date of your last visit? What was the reason for the visit? Vitamins/Supplements:
Do you have any environmental allergies or allergies to medications :

FAMILY MEDICAL HISTORY

Please select from the following drop down lists for any conditions in your family.
Such as: Arthritis, Cancer, Diabetes, HBP, Heart Dx, Lupus, Kidney, Thyroid, Other

Health Condition in Family Relationship
1)
2)
3)
4)
5)
6)

 

 

 

 

 

 

Please list any conditions or concerns not found in drop-down lists:

LIFESTYLE:
Occupation (Please select from list):    Employer:
Please list any Hobbies, Recreation, Sports in which you participate:
Computer Use (Please select from list):

Tobacco Use (Please select from list):    Type:  How Long:

Alcohol Consumption (Please select from list):  Type:  How Long:

Illegal Drugs Use (Please select from list):  Type:  How Long:

Do you have a history of any sexually transmitted disease(s)?

What are your latest glucose reading?  When was it taken?  

What was your latest HbA1C reading?  When was it taken?

 

Ocular History

REASON FOR VISIT
Please select the MAIN REASON for your visit or the chief complaint you wish to have addressed?

When was the ONSET of the problem was present?

Select the word(s) to best describe the LOCATION of the problem?

Please choose the word to describe the QUALITY of the problem?

Please select the word that best rates the SEVERITY of the problem.

What the DURATION of the problem.

How FREQUENTLY do you experience the problem?

Please select the word(s) that give CONTEXT, if appropriate.

Are there any MODIFYING behaviors. Please select if appropriate.

Are there any ASSOCIATED SYMPTOMS or signs of other problems.?

Please enter any other CONCERNS or COMPLAINTS.

Notes:


REVIEW OF OCULAR SYSTEM
Have you experienced any other Injuries, Infections, Surgeries, Diseases? If so, please list below.

Have you recently take any of the following ophthalmic EYE MEDICATION(S)? Please select all that apply.

When was your last EYE EXAM? Please select the value closest to the time period.

What was the NAME of the Eye Doctor?


FAMILY OCULAR HISTORY
Who in the family has a history or any of the following conditions? Please select relation from drop-down lists.
Glaucoma: Cataracts: Macular Degeneration:
Retinal Detachment: Crossed / Lazy eye(s):

Please add any comments needed to clarify or add any conditions you wish to mention.

Choose from the list which option best explains your typical form of OPTICAL CORRECTION.

Do you have a Back-Up form of correction?

Are you planning to get New Glasses?

What TYPE of CLs have you worn in past?

Please select the option that best describes your contact lensWEARING TIME.

Please select CL SOLUTION you used most recently.

Please select the word that best describes how often you DISPOSE of the LENSES.

Please choose from list the words that best describe you RACE.

Please choose from list the words that best describe your ETHNICITY.

Please choose from list the words that best describe your PREFERRED LANGUAGE.

Please enter any ADDITIONAL NOTES you feel we should know about you eye health history.

Ocular Surface Index


Please select one answer in each box for all ENVIRONMENTAL factors.

Please select one answer in each box for all SYSTEMIC CONDITIONS that apply.

Please select one answer in each box for all SYSTEMIC MEDICATIONS that apply.

Please select one answer in each box for all OCULAR MEDICATIONS that apply.
Please select one answer in each box for all OCULAR MOISTURE THERAPY that apply.
Please enter the number of Times/day you instill each medication.
Please select one answer in each box for all SIGNS OF A PROBLEM that apply.
Please select one answer in each box for all SYMPTOMS OF A PROBLEM that apply.

Do you experience any SENSITIVITY TO LIGHT?

Submit Data

After Completing All Forms Submit Data on Final Tab