New Patient Form
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:
Cell Phone:
Preferred Contact Method:
Home Phone
Work Phone
Cell Phone
Other Phone
Text Message
Email
SSN
Email
Birthday
Occupation
Sex
Male
Female
Employment Status
Employed
Full-Time Student
Part-Time Student
Marital Status
Annulled
Divorced
Domestic Partner
Interlocutory
Legally Separated
Married
Never Married
Polygamous
Widowed
Employer/School Name
Primary Doctor
No Doctor Assigned
Dr. Licup, Albert
Dr. Serenda, Marielle
Dr. Tan, Alex
Misc/Guardian
Billing Information
Is The Billing Address the Same?
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:
Primary
Insurance Information
Insurance Name:
None
Aetna Health Care
Aetna Student Health
Always Care
Assurant
Auxiant
Benefit Administrative Systems
Blue Cross Blue Shield of Illinois
Cigna(open access/PPO)
Department of Human Services
EyeMed Vision Care
Group Administrators, LTD
Humana/Choicecare
InfantSEE Assessment Service
L.H.I.
Medicare
MULTIPLAN,INC./PHCS
NVA(national vision administrators)
PBA/Multiplan
PHCS/ Meritain
Principal Life Insurance/ Multi plan
Rush Healh Associates
Self Pay
Tricare
Unicare(MULTIPLAN)
United Healthcare
VCP/CompBenefits
VSP
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:
None
Aetna Health Care
Aetna Student Health
Always Care
Assurant
Auxiant
Benefit Administrative Systems
Blue Cross Blue Shield of Illinois
Cigna(open access/PPO)
Department of Human Services
EyeMed Vision Care
Group Administrators, LTD
Humana/Choicecare
InfantSEE Assessment Service
L.H.I.
Medicare
MULTIPLAN,INC./PHCS
NVA(national vision administrators)
PBA/Multiplan
PHCS/ Meritain
Principal Life Insurance/ Multi plan
Rush Healh Associates
Self Pay
Tricare
Unicare(MULTIPLAN)
United Healthcare
VCP/CompBenefits
VSP
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:
None
Aetna Health Care
Aetna Student Health
Always Care
Assurant
Auxiant
Benefit Administrative Systems
Blue Cross Blue Shield of Illinois
Cigna(open access/PPO)
Department of Human Services
EyeMed Vision Care
Group Administrators, LTD
Humana/Choicecare
InfantSEE Assessment Service
L.H.I.
Medicare
MULTIPLAN,INC./PHCS
NVA(national vision administrators)
PBA/Multiplan
PHCS/ Meritain
Principal Life Insurance/ Multi plan
Rush Healh Associates
Self Pay
Tricare
Unicare(MULTIPLAN)
United Healthcare
VCP/CompBenefits
VSP
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
Pt rtc per Dr. Tan for yearly eye health exam
annual doctor directed diabetic eye exam
burning
distance vision blurry
dry eyes
failed screening at school
injury to eye
itching
loss of vision
near vision blurry
needs new glasses
pain in eye
red eye
state required kindergarten exam
stinging
vision blurry distance and near
wants to be fitted for contacts
Pt rtc for Glaucoma Eval per Dr. Tan
Pt Rtc for Repeat refraction per Dr. Tan
Pt Rtc for Dry Eye F/u per Dr. Tan
Pt here for cl fit
Pt here for Duette Fit
Pt here for Duette MF fit
Pt here for Duette Progressive fit
Pt here for crt fit/consult
Pt here for Cl I/R
Pt here for PP insertion per Dr. Tan
Pt here for DFE
Pt rtc for Cataract check
Pt rtc for AMD check per Dr. Tan
Other
Location
both eyes
right eye
left eye
Other
Timing
yesterday
today
1 week
2 weeks
1 month
gradual
longstanding
unknown
Other
Duration
constant
intermittent
mornings
evenings
Other
Severity
mild
moderate
severe
Other
Quality
no change
worse
better
Other
Context
classroom
computer
driving
outside
Other
Associated
blurred vision
dizzy
eye pain
headache
loss of vision
Other
Modifying
close eyes
glasses
remove contacts
remove glasses
warm compresses
Other
Additional History
Location
both eyes
right eye
left eye
Other
Secondary Complaint
Other
Timing
yesterday
today
1 week
2 weeks
1 month
gradual
longstanding
unknown
Other
Duration
constant
intermittent
mornings
evenings
Other
Severity
mild
moderate
severe
Other
Quality
no change
worse
better
Other
Context
classroom
computer
driving
outside
Other
Associated
blurred vision
dizzy
eye pain
headache
loss of vision
Other
Modifying
close eyes
glasses
remove contacts
remove glasses
warm compresses
Other
Additional History
Medical History
Race
White
African or African American
Asian
Hispanic or Latino
Native American or Alaskan Indian
Native Hawaiian or Other Pacific Islander
Other
Other
Ethnicity
<
Hispanic or Latino
Hispanic or Latino
Unknown
Patient Declined to Specify
Preferred Language
English
Chinese
French
German
Spanish
Other
Neuro
oriented to person, time, and place
Other
Psych
normal affect and mood
agitated
anxious
depressed
Other
Occupation
Hobbies
cooking
gardening
golf
reading
woodworking
Other
Last Eye Exam
6 months
1 year
2 years
3 years
4 years
5 years
> 5 years
first eye exam
Other
Ocular Condition 1
amblyopia
cataract
dry eye
glaucoma
macular degeneration
retinal detachment
Other
stable
currently monitored
monitored by OMD
Other
Ocular Condition 2
amblyopia
cataract
dry eye
glaucoma
macular degeneration
retinal detachment
Other
stable
currently monitored
monitored by OMD
Other
Ocular Condition 3
amblyopia
cataract
dry eye
glaucoma
macular degeneration
retinal degeneration
Other
stable
currently monitored
monitored by OMD
Other
Ocular Condition 4
amblyopia
cataract
dry eye
glaucoma
macular degeneration
retinal degeneration
Other
Last Eye Doctor
none
does not remember
Tan
Licup
Serenda
Other
stable
currently monitored
monitored by OMD
Other
blepharoplasty
tarsorrhapy
botox injection(s)
Other
OD
OS
OU
Other
Other
blepharoplasty
tarsorrhapy
botox injection(s)
Other
OD
OS
OU
Other
Other
blepharoplasty
tarsorrhapy
botox injection(s)
Other
OD
OS
OU
Other
Other
LASIK
PCIOL
PRK
RK
Other
OD
OS
OU
Other
Other
LASIK
PCIOL
PRK
RK
Other
OD
OS
OU
Other
Other
LASIK
PCIOL
PRK
RK
Other
OD
OS
OU
Other
Other
Avastin injection
brachytherapy
cryotherapy
focal grid laser
PRP
scleral buckle
Other
OD
OS
OU
Other
Other
Avastin injection
brachytherapy
cryotherapy
focal grid laser
PRP
scleral buckle
Other
OD
OS
OU
Other
Other
Avastin injection
brachytherapy
cryotherapy
focal grid laser
PRP
scleral buckle
Other
OD
OS
OU
Other
Other
Primary Care Physcian
none
Doesn't have one
does not remember
Sassetti
Kungl
Beemer
Liu
Manus
Haukness
Turk
Wegner
Claus
Taback
Other
Last Visit
6 months
1 year
2 years
Other
Height
Weight
Medical Condition 1
arthritis
cancer
diabetes
heart disease
HIV
hypercholesterolemia
hypertension
thyroid disease
Other
controlled
fluctuate
not under medical care
Other
Medical Condition 2
arthritis
cancer
diabetes
heart disease
HIV
hypercholesterolemia
hypertension
thyroid disease
Other
controlled
fluctuate
not under medical care
Other
Medical Condition 3
arthritis
cancer
diabetes
heart disease
HIV
hypercholesterolemia
hypertension
thyroid disease
Other
controlled
fluctuate
not under medical care
Other
Medical Condition 4
arthritis
cancer
diabetes
heart disease
HIV
hypercholesterolemia
hypertension
thyroid disease
Other
controlled
fluctuate
not under medical care
Other
Medical Condition 5
arthritis
cancer
diabetes
heart disease
HIV
hypercholesterolemia
hypertension
thyroid disease
Other
controlled
fluctuate
not under medical care
Other
Medical Condition 6
arthritis
cancer
diabetes
heart disease
HIV
hypercholesterolemia
hypertension
thyroid disease
Other
controlled
flucatuate
not under medical care
Other
Other Medical History/Injuries/Surgeries/Hospitalization
Pregnant Or Nursing
no
yes
unsure
Other
Glucometry
unknown
Other
Taken
today
yesterday
Other
HbA1C
unknown
Other
Taken
1 month ago
2 months ago
3 months ago
4 months ago
5 months ago
> 6 Months
Other
Smoking Status
Never smoker (<100 lifetime cigarettes or equivalent quantity of cigar or pipe smoke)
Former smoker (no longer smokes)">Former smoker (no longer smokes)">Former smoker (no longer smokes)
Current some day smoker (not daily)
Light smoker (<10 cigs/day)
Heavy smoker (>10 cigs/day)
Smoker (current status unknown)
Smoker (current status unknown)
Unknown if ever smoked
Other
Type
cigarettes
cigar
chewing tobacco
Other
Year Started
Year Quit
Discussed Cessation
no
yes
Other
Alcohol Use
no
socially
yes
Other
Type
beer
wine
hard liquor
Other
Recreational Drug
no
yes
Other
Type
cocaine
heroin
marijuana
Other
Year Started
Year Quit
Sexually Transmitted Disease
none
chlamydia
gonorrhea
hepatitis
herpes
syphilis
Other
Amblyopia
no
aunt
brother
father
grandmother
granfather
mother
sister
uncle
Other
Eye Tumor
no
aunt
brother
father
grandfather
grandmother
mother
sister
uncle
Other
Glaucoma
no
aunt
brother
father
grandfather
grandmother
mother
sister
uncle
Other
Macular Degeneration
no
aunt
brother
father
grandfather
grandmother
mother
sister
uncle
Other
Retinal Detachment
no
aunt
brother
father
grandfather
grandmother
mother
sister
uncle
Other
Other Family Ocular History
Cancer
no
aunt
brother
father
grandfather
grandmother
mother
sister
uncle
Other
Diabetes
no
aunt
brother
father
grandfather
grandmother
mother
sister
uncle
Other
Hypertension
no
aunt
brother
father
grandfather
grandmother
mother
sister
uncle
Other
Hypercholesterolemia
no
aunt
brother
father
grandfather
grandmother
mother
sister
uncle
Other
HIV/AIDS
no
aunt
brother
father
grandfather
grandmother
mother
sister
uncle
Other
Other Family Medical History
No Current Prescription Medication(s) Reported
No Known Drug Allergies Reported
No Ocular Conditions Reported
No Ocular Surgeries Reported
No Medical Conditions Reported
Non-Drug Allergy
Primary Insurance
Secondary Insurance
Compass Eyecare
Private practice OD
Retail OD
OMD
Declined to provide weight
OTC
Unknown name of medications taken for:
Ocular Condition 6
amblyopia
cataract
dry eye
glaucoma
macular degeneration
retinal degeneration
Other
Ocular Condition 5
amblyopia
cataract
dry eye
glaucoma
macular degeneration
retinal degeneration
Other
stable
currently monitored
monitored by OMD
Other
stable
currently monitored
monitored by OMD
Other
Technician
Mark
Yadi
Maureen
Other
Review of Systems
GENERAL: Fever, weight loss, weight gain, fatigue?
none
Other
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus
none
Other
BLOOD/LYMPH: Anemia, Bleeding Problems
none
Other
CARDIOVASCULAR: High Blood Pressure, Cholesterol, Heart Disease
none
Other
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat
none
Other
ENDORCRINE: Thyroid, Diabetes
none
Other
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux
none
Other
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, Impotence
none
Other
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury
none
Other
NEUROLOGICAL: Headaches, Migraines, Seizures
none
Other
PSYCHIATRIC: Depression, Anxiety, Insomnia
none
Other
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD
none
Other
SKIN: Growths, Rashes, Acne
none
Other
Submit Data
After Completing All Forms Submit Data on Final Tab