New Patient Form

Demographics

First NameLast NameMINickname
Address:
City: State/ZipCode
Home Phone:
Cell Phone:
Email
Birthday Occupation
Sex Male Female
Guardian

MEDICAL HISTORY
Briefly describe the main reason for having an examination today:
____________________________________________________________________________________________________________________________________________________________
Past illness or injuries:
Past Surgeries:
Systemic Medications: No current medication.


Do you have any allergies to medications? NO YES    If yes, please list:
Are you pregnant or nursing?No YES    If yes, how long?
______________________________________________________________________________________________________________________________________________________
SOCIAL HISTORY
This information is required by insurance carriers and is kept strictly confidential.
Do you use tobacco products? NO YES If yes, type/amount/how often:
Do you drink alcohol? NO YES If yes, type/amount/how often:
Do you use illegal drugs? NO YES If yes, type/amount/how often:
______________________________________________________________________________________________________________________________________________________
FAMILY HISTORYFamily history is unknown/adopted
Please note any family members (parents, grandparents, siblings, and childrens) with the following condition
NO YES RELATIONSHIP TO PATIENT
Blindness
Eye turn (strabismus)
Lazy Eye (amblyopia)
Glaucoma
Cataract
Macular Degeneration
Retinal Detachment/Disease
Cancer
Diabetes
High Blood Pressure
Heart Disease
Thyroid Disease
Other
______________________________________________________________________________________________________________________________________________________
REVIEW OF SYSTEMS
Do you currently have any of the following?
NO YES NO YES
CONSTITUTIONAL RESPIRATORY
Fever Asthma
Weight Loss/Gain Bronchitis
NEUROLOGICAL CARDIOVASCULAR
Headaches Heart Disease
Migraines High Blood Pressure
Seizures Stroke
Mulitple Sclerosis Cholesterol
EYES BONES/JOINTS/MUSCLE
Blurry vision Rheumatoid Arthritis
Loss of Vision Muscle Pains
Distorted Vision/Halos Joint Pains
Double Vision ENDOCRINE
Dryness Thyroid
Mucous Discharge Diabetes
Redness PSYCHIATRIC
Sandy/Gritty Feeling Depression
Itchy Bipolar
Burning GASTROINTESINAL
Excess Tearing/Watering Diarrhea
Glare/Light Sensitivity Constipation
Eye Pain or Soreness GENITOURINARY
Infection of Eye or Lids Genital/Kidney/Bladder
Styes or Chalazion LYMPHATIC/HEMATOLOGIC
Flashes/Floater Anemia
EAR/NOSE/THROAT Bleeding
Allergies/Hay fever
Chronic Cough
Sinus Congestion

If you answered YES to any of the above or have a condition not listed, please explain: