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:

Chief Complaint

Chief Complaint
Location
Timing
Duration
Severity
Quality
Context
Associated
Modifying
Additional History
Location
Secondary Complaint
Timing
Duration
Severity
Quality
Context
Associated
Modifying
Additional History

Medical History

Race
Ethnicity
Preferred Language
Neuro
Psych
Occupation
Hobbies
Last Eye Exam
Ocular Condition 1
Ocular Condition 2
Ocular Condition 3
Ocular Condition 4
Last Eye Doctor
Primary Care Physcian
Last Visit
Height
Weight
Medical Condition 1
Medical Condition 2
Medical Condition 3
Medical Condition 4
Medical Condition 5
Medical Condition 6
Other Medical History/Injuries/Surgeries/Hospitalization
Pregnant Or Nursing
Glucometry
Taken
HbA1C
Taken
Smoking Status
Type
Year Started
Year Quit
Discussed Cessation
Alcohol Use
Type
Recreational Drug
Type
Year Started
Year Quit
Sexually Transmitted Disease
Amblyopia
Eye Tumor
Glaucoma
Macular Degeneration
Retinal Detachment
Other Family Ocular History
Cancer
Diabetes
Hypertension
Hypercholesterolemia
HIV/AIDS
Other Family Medical History
No Current Prescription Medication(s) Reported No Known Drug Allergies ReportedNo Ocular Conditions ReportedNo Ocular Surgeries ReportedNo Medical Conditions Reported
Non-Drug Allergy
Primary Insurance
Secondary Insurance
Compass EyecarePrivate practice ODRetail OD OMD Declined to provide weight
OTC
Unknown name of medications taken for:
Ocular Condition 6
Ocular Condition 5
Technician

Review of Systems

GENERAL: Fever, weight loss, weight gain, fatigue?
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus
BLOOD/LYMPH: Anemia, Bleeding Problems
CARDIOVASCULAR: High Blood Pressure, Cholesterol, Heart Disease
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat
ENDORCRINE: Thyroid, Diabetes
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, Impotence
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury
NEUROLOGICAL: Headaches, Migraines, Seizures
PSYCHIATRIC: Depression, Anxiety, Insomnia
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD
SKIN: Growths, Rashes, Acne

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