New Patient Form - Please fill out each tab

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:
SS# _ _ _ -_ _ -_ _ _ _		Email
DOB mm/dd/yyyy		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		How did you hear about us?	Existing patient Email Marketing Google Advertisement Google Search Google Search Google Reviews Yelp Insurance Website Word of Mouth Other

Billing Information

Check Here if the Billing Address is the Same as Above

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 BlueCross BlueShield Davis Vision Eyemed Humana Vision Care Plan Optumhealth Vision (Spectera) Sightcare Superior Vision Vision Care Direct Vision Service Plan
Insurance ID:
Insurance Policy Group:

If you are NOT the Primary on this insurance, please check this box and complete the following:

Primary Insured's Information

Name:	Last, First MI
DOB mm/dd/yyyy
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Employer/School:
Your Relationship to Insured:	Spouse Child Other

Medical Insurance

Insurance Information

Insurance Name:	None AARP Administrative Enterprises Aetna Healthplan Ameriben Solutions ASBAIT-Administrative Enterprises BlueCross BlueShield Cigna Coventry Healthare First Health Gilsbar Golden Rule Healthnet Medicare Part B / Noridian MMSI Private Pay Railroad Medicare Scan Healthplan Tricare UnitedHealthcare
Insurance ID:
Insurance Policy Group:

If you are NOT the Primary on this insurance, please check this box and complete the following:

Primary Insured's Information

Name:	Last, First MI
DOB mm/dd/yyyy
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Employer/School:
Your Relationship to Insured	Spouse Child Other

Medical History

  Welcome to Insight Eyecare & Eyewear-Please fill out all applicable fields
Section 1 - VISUAL HISTORY:
Briefly describe the main reason for having an examination today: 

Other eye issues or problems?


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

Are you currently experiencing any of the following? SET ALL TO NO	YES	NO
Headaches
Blurred Vision
Double Vision
Eyes "hurt" or "tired"
Eye pain or soreness
Halos around lights
Bothered by light/sun light
Frequent styes
Eyes frequently red
Infection of eye or lid
Itchy Eyes
Burning Eyes
Watery Eyes
Dry Eyes
Eyes feel sandy/gritty
Mucous Discharge
Floaters
Loss of vision
Flashing lights

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you have a history of any of the following? SET ALL TO NO	YES	NO
Blindness
Eye Turn (Strabismus)
Lazy Eye (Amblyopia)
Keratoconus
Glaucoma
Cataracts
Macular Degeneration
Retinal Detachment

 

 

 

 

 

 

 

 

Other eye disease or condition: 
Describe any eye injuries: 
List any eye surgeries: 


How many hours a day do you use a computer?  <2 hours 2 - 4 hours 5 - 8 hours 9 - 12 hours 12+ hours
How far away from your eyes is your computer monitor? 
Describe any visual symptoms from computer use:


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


CONTACT LENS WEARERS:
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

---

Section 2 - 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?   

Have you ever experienced problems in the following areas? 

CONSTITUTIONAL	None	NEUROLOGICAL	None	RESPIRATORY	None
Fever		Headaches		Asthma
Weight Loss		Migraines		COPD
Other		Stroke		Emphysema
CARDIOVASCULAR	None	Multiple Sclerosis		Lung Cancer
High Blood Pressure		Alzhiemer's		MUSKULOSKELETAL	None
Cholesterol		Parkinson's		Rheumatoid Arthritis
Heart Disease		IMMUNOLOGY/ALLERGY	None	Osteoporosis
Heart Failure		HIV		Fibromyalgia
Arrhythmias		Allergy to Metals		ENDOCRINE	None
Vascular Disease		PSYCHIATRIC	None	Diabetes
GASTROINTESTINAL	None	Anxiety		Thyroid Dysfunction
Ulcers		Depression		Pituitary Dysfunction
Intestinal Polyps		Drug Dependence		HEMATOLOGIC/BLOOD	None
Reflux Disease		Alcoholism		Anemia
Cancer		Bipolar or Schizophrenia		Bleeding Disorder
INTEGUMENTARY (SKIN)	None	EARS/NOSE/THROAT	None	Other
Rosacea		Allergies		GENITOURINARY	None
Psoriasis		Sinus Congestion		Urinary Tract Infection
Skin Cancer		Dry Mouth/Throat		Renal (Kidney) Failure
		Hearing Loss		Prostate/Ovarian Cancer

List any other diseases here: 

---

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	High 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	Other Inherited Disease		Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Macular Degeneration		Mother Father Sister Brother Aunt Uncle Grandmother Grandfather	If yes, what disease?
Retinal Detachment/Disease		Mother Father Sister Brother Aunt Uncle Grandmother Grandfather

---

Section 4 - 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? Hepatitis  HIV STDs None
Occupation:                Employer:

---

Section 5 - Who referred you to Insight Eyecare & Eyewear:   
If not referred, how did you hear about Insight Eyecare?   Please Select: Google Ad Family member Insurance list Coworker Friend Primary Care Doctor Internet Search Drive by 0ther                                                       

Submit Data

It is our mission to provide you with extraordinary service and the most comprehensive, up-to-date, and personalized solution for your unique visual needs. To ensure the best experience possible, it is critical that we reserve adequate time your upcoming office visit. For this reason, please arrive 10-15 minutes prior to your scheduled appointment time. This allows us to process paperwork, obtain new insurance cards, and update important information that is needed before your exam.


Cancellation Policy

Our patient schedule has been carefully designed to reserve adequate time for your individual care, and it is our top priority to value and respect your time. If you are unable to make your appointment for any reason, it is important that you call us at (480) 883-0900 as soon as possible so we can make other arrangements for you. Please contact our office by phone at least 24-hours in advance of your scheduled time with us in order to avoid a $75 Cancellation Charge to your account.


Thank you for choosing Insight Eyecare and Eyewear for all of your vision needs.

We look forward to seeing you soon!