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. Son, Christopher Dr. Nguyen, Audrey Dr. Associate, OD	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:

Primary

Insurance Information

Insurance Name:	None AARP AETNA Anthem BCBS BLUE CROSS BLUE SHIELD Carefirst BCBS CBA Cigna Compass Rose Coventry Eyemed FEP BCBS GEHA Golden Rule Golden Rule Great West Humana Humana VCP Medicaid Medicare Mutual of Omaha New York Life OneNet STATE FARM Superior Vision Tricare UMR United American Ins. Company United Healthcare USAA 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 AARP AETNA Anthem BCBS BLUE CROSS BLUE SHIELD Carefirst BCBS CBA Cigna Compass Rose Coventry Eyemed FEP BCBS GEHA Golden Rule Golden Rule Great West Humana Humana VCP Medicaid Medicare Mutual of Omaha New York Life OneNet STATE FARM Superior Vision Tricare UMR United American Ins. Company United Healthcare USAA 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 AARP AETNA Anthem BCBS BLUE CROSS BLUE SHIELD Carefirst BCBS CBA Cigna Compass Rose Coventry Eyemed FEP BCBS GEHA Golden Rule Golden Rule Great West Humana Humana VCP Medicaid Medicare Mutual of Omaha New York Life OneNet STATE FARM Superior Vision Tricare UMR United American Ins. Company United Healthcare USAA 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:

Medical History

CHIEF COMPLAINT
distance vision blurry near vision blurry vision blurry distance and near red eye pain in eye loss of vision injury to eye needs new glasses wants to be fitted for contacts itching burning stinging dry eyes Diabetic eye exam

SECONDARY COMPLAINTS:


FAMILY OCULAR HISTORY

Crossed / Lazy:
No Parents Siblings Grandparent

Retinal Detach:
No Parents Siblings Grandparent

Macular Degen:
No Parents Siblings Grandparent

Cataracts:
No Parents Siblings Grandparent

Glaucoma:
No Parents Sibling Grandparent

REVIEW OF SYSTEMS:
Do You Currently Have Any Of These Problems?

GENERAL: Fever, weight loss, weight gain, fatigue?
None Fever Weight Loss Weight Gain Fatigue

EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat
None Allergies Sinus Problems Chronic Cough Dry Throat / Mouth Hard of Hearing

CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease
None High BP Surgery Vascular Disease

RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD
None Asthma Bronchitis Emphysema COPD

MUSCLES, BONES, JOINTS: Athritis, Joint Pains, Head or Neck Injury
None Joint pain Stiffness Swelling Cramps Arthritis

SKIN: growths, rashes, acne
None Pimples, Warts Growths Rash

NEUROLOGICAL: Headaches, migraines, seizures
None Numbness, Paralysis Headache Seizures Migraines

PSYCHIATRIC: Depression, Anxiety, Insomnia
None Anxiety Depression Insomnia

ENDORCRINE: Thyroid, Diabetes
None Diabetes Hypothyroid Hyperthoyroid

BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
None High Cholestrol Anemia

ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus
None Sneezing Swelling Redness Itching Hives Lupus

FAMILY MEDICAL HISTORY: Diabetes, HBP, Heart Dz, Cancer, Athritis, Lupus, Kidney, Thyroid, Other

None Adopted Athritis Cancer Cardiovascular Disease Diabetes HBP Kidney Disease Lupus Thyroid

None Adopted Athritis Cancer Cardiovascular Disease Diabetes HBP Kidney Disease Lupus Thyroid

None Adopted Athritis Cancer Cardiovascular Disease Diabetes HBP Kidney Disease Lupus Thyroid

None Adopted Athritis Cancer Cardiovascular Disease Diabetes HBP Kidney Disease Lupus Thyroid

None Adopted Athritis Cancer Cardiovascular Disease Diabetes HBP Kidney Disease Lupus Thyroid

None Adopted Athritis Cancer Cardiovascular Disease Diabetes HBP Kidney Disease Lupus Thyroid

HEIGHT: FOOT 0 1 2 3 4 5 6 7 8 9 10 11 12 INCHES

WEIGHT: POUNDS

TOBACCO: Non-Smoker Smoker Unknown

ALCOHOL: No Yes Occasionally Socially

PREFERRED LANGUAGE: English French German Spanish

ETHNICITY: Non Hispanic or Latino Hispanic or Latino

RACE: White American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander Declined

Notice Of Privacy Practices

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I certify that I have been made aware of Dr. Son and Associates' Notice of Privacy Practices and that I have a right to receive a copy upon request. This Notice describes the type of uses and disclosures of my protected health information that might occur during my treatment, to facilitate the payment of my bills or in the performance of Dr. Son and Associates' health care operations. The Notice also describes my rights and Dr. Son and Associates' duties with respect to my protected health information. I understand that copies of the Notice of Privacy Practices are available at the front desk. I may request that a copy be mailed to me by calling 703-748-1366

Dr. Son and Associates reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by calling the above number and requesting a revised copy be mailed to me, by asking for one at the time of my next appointment.

SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE
NAME OF PATIENT OR PERSONAL REPRESENTATIVE
DATE
DESCRIPTION OF PERSONAL REPRESENTATIVE'S AUTHORITY

Retinal Photos

RETINAL PHOTOGRAPHY

A new, highly sophisticated, digital camera now enables us to provide a more thorough retinal analysis of your eyes. Photo-documentation is painless and in most cases can substitute a dilated examination of your retina. It can also be an excellent reference point from which future comparison can be made.

Retinal photography can assist us in the early detection of optic nerve disease, pre-cancerous lesions, macular degeneration, hypertensive retinopathy, diabetic retinopathy, any many other retinal disorders such as retinal detachment, holes, and thinning.

We strongly recommend that all of our patients receive this test. It is especially important for all people over the age of 35, as well as those patients who have a history of high blood pressure, diabetes, retinal problems, headaches, or a strong prescription for glasses.

There is an additional charge of $39 for the retinal photography. Please indicate if you would like to opt for this evaluation.

I DO want the retinal photography I DO NOT want the retinal photography

Please note: While this test is "optional" for some people as it represents preventative health care, for others, retinal photo-documentation is "required" because of certain retinal conditions that may be present or need to be "ruled out." In this latter case, you may be able to submit your bill for the retinal photography to your major medical insurance company for possible reimbursement.

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