New Patient Form

Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev.

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	Unknown Single Married Separated Divorced Widowed Child	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Eck, Jonathan Dr. Ohde, Tyler	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev.

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 Aetna Avesis BCBS Cigna EyeMed Friends and Family Humana Medicare New Insurance Spectera Superior Vision United Health Care VCP VSP Windsor Sterling
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:

Primary Medical Insurance

Insurance Information

Insurance Name:	None Aetna Avesis BCBS Cigna EyeMed Friends and Family Humana Medicare New Insurance Spectera Superior Vision United Health Care VCP VSP Windsor Sterling
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 Medical Insurance

Insurance Information

Insurance Name:	None Aetna Avesis BCBS Cigna EyeMed Friends and Family Humana Medicare New Insurance Spectera Superior Vision United Health Care VCP VSP Windsor Sterling
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

Age

Sex

M F

Race

(Declined) American Indian or Alaska Native Black or African American Chinese El Salvadoran Hispanic Japanese Native Hawaiian or Pacific Islander Vietnamese White

Ethnicity

(Declined) Hispanic or Latino Not Hispanic or Latino

Recreational Drugs

Yes No

Alcohol

Yes No occasionally socially

Smoking Status

current every day smoker current some days smoker current status unknown former smoker never smoker smoker unknown if ever smoked

Patient Height FT

1 2 3 45 6 7 8 910

IN

1 2 3 45 6 7 8 910 11 12

Patient Weight

LBS

Blood Pressure

Received Influenza Immunization

Yes No

Triglycerides

Total Cholesterol

LDL

HDL

HbA1c

No Known Drug AllergiesNo Current Medications

Allergies

Ophthalmic Medications

Systemic Medications

Past Medical History

Family Ocular History

Family Medical History

Past Ocular History

CONSTITUTIONAL SYSTEM

no known problems chills Fever heat or cold intolerance night sweats weakness weight change malaise

ENT

no known problems cough dry mouth dry nasal passages frequent sore throat hearing loss history of bleeding gums history of ear surgery history of nasal obstruction history of nose bleeds history of seasonal allergies history of sinus infection histroy of swollen glands hoarseness post nasal drip runny nose swollen glands tinnitis

CARDIOVASCULAR

no known problems chest pain or tightness history of arteriosclerosis history of Giant Cell Arteritis history of hypercholestemia history of hypertension history of peripheral artery disease history of previous heart attack history vascular disease irregular heart beat mitral valve prolapse shortness of breath

RESPIRATORY

no known problems coughing difficulty breating history of history of asthma history of bronchitis history of COPD history of cystic fibrosis history of pnuemonia history of tuberculosis sneezing wheezing

GENITOURINARY

no known problems frequent urination history of impotence history of kidney failure history of kidney stones history of prostate cancer history of prostate hypertrophy Kidney stones painful urination

MUSCULOSKELETAL

no known problems back pain cramps hisory of Sjogren's history of Ankylosing Spondylitis history of arthritis history of fibromaylgia history of Gout history of Myasthenia Gravis history of Osteopenia history of Paget's disease history of Rheumatoid arthritis history of Systemic Lupus Erythromatosis history or Osteoporsis histoy of Sarcoidosis histroy of Marfan's sysndrome joint pain muscle tenderness muscle weakness stiffness swelling

INTEGUMENTARY

no known problems erythema growths history of acne history of Acne Rosacea history of Atopic dermatitis history of basal cell carcinoma history of Eczema history of Erythema Nodosum history of melanoma history of Psoriasis history of squamous cell carcinoma hives itching petechia rash warts

NEUROLOGIC

dizziness headache history of alzheimers history of fainting spells history of Migraines history of Multiple Sclerosis history of paralysis history of Parkinson's disease history of siezures history of tumor no known problems numbness tingling

PSYCHIATRIC

no known problems anxious depressed hallucinations history of ADD history of ADHD history of anxiety history of Bipolar disorder history of depression history of insomnia history of schizophrenia nervousness

ENDOCRINE

no known problems history of Cushing's syndrome history of diabetes Type 1 IDDM history of diabetes Type II history of hypothyroidism history of Parathyroid dysfunction histroy of Adrenal gland dysfunction histroy of hyperthyroidism histroy of Pituitary gland dysfunction

HEMATOLOGIC/LYMPHATIC

no known problems history of anemia history of Leukemia history of Lymphoma history of Non-Hodgkin's lymphoma history of other blood disorders histroy of polycythemia

ALLERGIC/IMMUNOLOGIC

no known problems bee stings edema erythema history chronic allergies history of allergy to insect bites history of food allergies history of HIV history of Lupus Erythematosis history of Lyme disease history of Sarcoidosis history of seasonal allergies hives Itching sneezing

GASTROINTESTINAL

no known problems abdominal pain constipation diarhea excessive thirst heartburn hisory of Hepatitis history of Celiac disease history of diverticulitis history of food intolerance history of Gall Bladder dysfunction history of GERD history of Gluten intolerance history of IBS history of liver dysfunction history of ulcers nausea swallowing dysfunction vomiting

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