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:

Medical History

PATIENT MEDICAL HISTORY
Please select any problems you may have from the drop downs below.

Please list any Injuries, Surgeries, Hospitalization
Pregnant Or Nursing: Recent Tetanus Shot:
Primary Care Physcian: Last Visit: Reason For Visit:
List any Vitamins you take:
Please list any over the Counter medications:
Please list your current Prescription Medications: No Current Medications
Please list all drug allergies: No Known Drug Allergies

FAMILY MEDICAL HISTORY
Do you have a history of any of the following in your family? (Please select from the drop downs below.)


Occupation: Hobbies:
Smoking Status: Type: How Long:
Alcohol: Type: How Long:
Illegal Drugs: Type: How Long: STD:

PATIENT OCULAR HISTORY
Please list all eye problems you have had:
(Itching, Burning, Amblyopia, Eye Injuries, Surgery, Flashes of Light, Floaters, Strabismus, Catatracts, Glaucoma, Retinal Disorders, etc)

List all your current eye medications
Last Eye Doctor: Last Eye Exam:
 
FAMILY OCULAR HISTORY

Glaucoma: Crossed / Lazy: Retinal Detach: Macular Degeneration: Cataracts:

Primary Vision Correction:   Planning to get new glasses?  Back up specs?

Type of CLs worn in past:  Wear Time: Cleaner: Disposal:

Preferred Language:  Ethnicity:   Race: 
 

DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?
GENERAL: Fever, weight loss, weight gain, fatigue?
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury
SKIN: growths, rashes, acne
NEUROLOGICAL: Headaches, migraines, seizures
PSYCHIATRIC: Depression, Anxiety, Insomnia
 ENDOCRINE: Thyroid, Diabetes
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, M.S., Lupus, HIV
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux






















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