Franklin Family Eyecare - 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	Single Married Separated Divorced Widowed Unknown	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Ngong, Josephine	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 ="""" AARP Aetna Aetna Choice PSO ii Americhoice Amerigroup AmeriHealth Anthem Blue Cross Blue Shield Avesis Block Vision Blue Cross Blue Shield Cigna Davis Vision Discount Plan Empire BLUE Empire Blue Cross Empire Blue Cross Blue Shield EyeMed Vision Care Health first Healthfirst NJ Horizon Bcbs Horizon Blue Cross Blue Shield Horizon Medicare Blue Access Horizon NJ Healthcare Independence Blue Cross Independent Health PHCS Network March Vision Medicaid Medicare Medicare / medicaid medicare and Medicaid Multi Plan PHCS Mutual of Omaha n/A No insurance None NVA NY Life Employees, Aetna NY Optum Health Vision Oxford Oxford / UHC PHCS Private Pay Qualcare self self pay Spectera Superior Vision TOS Discount Tri-Care Prime Tricare Trustmark Ins United Health Care United Health Care - Oxford United Health Care / MArch United Health Care / March Vision care USaa Van Breda Vision Service Plan 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 Aetna Choice PSO ii Americhoice Amerigroup AmeriHealth Anthem Blue Cross Blue Shield Avesis Block Vision Blue Cross Blue Shield Cigna Davis Vision Discount Plan Empire BLUE Empire Blue Cross Empire Blue Cross Blue Shield EyeMed Vision Care Health first Healthfirst NJ Horizon Bcbs Horizon Blue Cross Blue Shield Horizon Medicare Blue Access Horizon NJ Healthcare Independence Blue Cross Independent Health PHCS Network March Vision Medicaid Medicare Medicare / medicaid medicare and Medicaid Multi Plan PHCS Mutual of Omaha n/A No insurance None NVA NY Life Employees, Aetna NY Optum Health Vision Oxford Oxford / UHC PHCS Private Pay Qualcare self self pay Spectera Superior Vision TOS Discount Tri-Care Prime Tricare Trustmark Ins United Health Care United Health Care - Oxford United Health Care / MArch United Health Care / March Vision care USaa Van Breda Vision Service Plan 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 Aetna Choice PSO ii Americhoice Amerigroup AmeriHealth Anthem Blue Cross Blue Shield Avesis Block Vision Blue Cross Blue Shield Cigna Davis Vision Discount Plan Empire BLUE Empire Blue Cross Empire Blue Cross Blue Shield EyeMed Vision Care Health first Healthfirst NJ Horizon Bcbs Horizon Blue Cross Blue Shield Horizon Medicare Blue Access Horizon NJ Healthcare Independence Blue Cross Independent Health PHCS Network March Vision Medicaid Medicare Medicare / medicaid medicare and Medicaid Multi Plan PHCS Mutual of Omaha n/A No insurance None NVA NY Life Employees, Aetna NY Optum Health Vision Oxford Oxford / UHC PHCS Private Pay Qualcare self self pay Spectera Superior Vision TOS Discount Tri-Care Prime Tricare Trustmark Ins United Health Care United Health Care - Oxford United Health Care / MArch United Health Care / March Vision care USaa Van Breda Vision Service Plan 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

VISUAL HISTORY:
Briefly describe the main reason for having an examination today:

Associated: Do you have any other symptoms related to this?
none dizzy headache loss of vision blurred vision
Other eye issues or problems

I currently wear glasses: Part-time Full-time
If part-time, how often/when? Occasionally Driving Reading / Computer After contact lens removal 1-2 times per week Half time Sports Weekends Social activities
I currently wear contacts: Part-time Full-time
If part-time, how often/when? Occasionally Driving 1-2 times per week Half time Sports Weekends Social activities
Contact lens wearers: Are your lenses comfortable? Yes No
Rigid Gas Permeable Soft
What solution do you use? None Optifree Replenish Optifree Pure Moist Optifree Express Renu Biotrue Clear Care Kirkland Signature Revitalens Generic store brand Boston Advance Boston original Optimum B & L Gas Perm Unique Ph
Current Brand: Acuvue 1-day Acuvue 1-day Moist Acuvue 1-day Trueye Acuvue 2 Acuvue Oasys Acuvue Oasys for Astigmatism Acuvue Oasys for Presbyopia Acuvue Advance Acuvue Advance for Astigmatism Air Optix Air Optix Night & Day Air Optix Astigmatism Air Optix Multifocal Avaira Biomedic Toric Biomedic XC Biofinity Biofinity Toric Biofinity Multifocal Clearsight 1 day Clearsight 1 day Toric Focus Dailies Standard Focus Dailies AC plus Focus Dailies Toric Frequency 55 Frequency 55 Toric Frequency 55 Aspheric Freshlook colorblends Proclear Proclear 1 day Proclear EP Proclear Multifocal Purevision Purevision 2 Purevision 2 Toric Purevision Multifocal Soflens 38 Soflens Toric Soflens Daily Disposable Soflens Multifocal Vertex Toric Boston EO Boston ES Boston XO Fluoroperm 60 Menicon Z Thin RGP - unknown material
What is your replacement schedule? Daily Weekly Every 2 weeks Monthly If they feel bad Quarterly Yearly
How old is your current pair? new 1-2 weeks 2-4 weeks very old Please list all eyedrops you use (OTC and Rx): none Blink Genteal Optive Refresh Plus Similisan Systane Generic artificial tears Murine Visine Lumigan Travatan Xalatan Timoptic
How often used? daily occasionally rarely

Do you have a history of any of the following?
Blindness
Yes No
Eye Turn (Strabismus)
Yes No
Lazy Eye (Amblyopia)
Yes No
Keratoconus
Yes No
Macular Degeneration
Yes No
Retinal Detachment
Yes No
Glaucoma
Yes No
Cataracts
Yes No

Are you currently experiencing any of the following?
Headaches
Yes No
Blurred Vision
Yes No
Double Vision
Yes No
Eyes "hurt" or "tired"
Yes No
Floaters
Yes No
Flashing lights
Yes No
Eyes feel sandy/gritty
Yes No
Halos around lights
Yes No
Bothered by light/sun
Yes No
Frequent styes
Yes No
Eyes frequently red
Yes No
Eyes itch
Yes No
Eyes burn
Yes No
Eyes tear
Yes No
Eyes feel dry
Yes No

List any eye surgeries:
Other eye disease or condition:
Describe any eye injuries:
How many hours a day do you use a computer? <2 hours 2 - 4 hours 5 - 8 hours 9 - 12 hours 12+ hours
Describe any visual symptoms from computer use: none Eye strain Blurred vision Headache Dry eyes Watery Itch Burn Double vision

______________________________________________________________________________________________________________________________________________________
MEDICAL HISTORY / REVIEW OF SYSTEMS:
Physician's Name:
Last Visit Date:
List all medications you are currently taking (including any OTC/vitamins):

Allergies/Alerts:

Height Weight Are you pregnant or nursing? Yes No
If yes, what is the due/birth date?

Do you have, or ever had, any CHRONIC problems in the following areas?
Migraines
Yes No
Multiple Sclerosis
Yes No
Diabetes
Yes No
Thyroid problems
Yes No

Arthritis
Yes No
Allergies/Hay fever
Yes No
Asthma
Yes No
Emphysema
Yes No

High blood pressure
Yes No
Stroke
Yes No
Anemia
Yes No
Cancer
Yes No
Notes:

______________________________________________________________________________________________________________________________________________________
FAMILY HISTORY Family history is unknown/adopted
Any history of the following in any family members (parents, grandparents, siblings, children)?
Poor Vision Yes No
RELATIONSHIP TO PATIENT Mother Father Sister Brother Aunt Uncle Grandmother Grandfather

Blindness Yes No
RELATIONSHIP TO PATIENT Mother Father Sister Brother Aunt Uncle Grandmother Grandfather

Eye turn (Strabismus) Yes No
RELATIONSHIP TO PATIENT Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Lazy Eye (Amblyopia) Yes No
RELATIONSHIP TO PATIENT Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Glaucoma Yes No
RELATIONSHIP TO PATIENT Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Cataracts Yes No
RELATIONSHIP TO PATIENT Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Macular Degeneration Yes No
RELATIONSHIP TO PATIENT Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Retinal Detachment/Disease Yes No
RELATIONSHIP TO PATIENT Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Cancer Yes No
RELATIONSHIP TO PATIENT Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Diabetes Yes No
RELATIONSHIP TO PATIENT Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
High Blood Pressure Yes No
RELATIONSHIP TO PATIENT Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Stroke Yes No
RELATIONSHIP TO PATIENT Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Thyroid Disease Yes No
RELATIONSHIP TO PATIENT Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Other Inherited Disease Yes No
RELATIONSHIP TO PATIENT Mother Father Sister Brother Aunt Uncle Grandmother Grandfather If yes, what disease? ______________________________________________________________________________________________________________________________________________________
SOCIAL HISTORY (confidential)
How often do you smoke/use tobacco products? Never Occasionally Daily
How often do you consume alcohol: Never Occasionally Daily
Do you have? HIV Hepatitis STDs
Occupation: Employer:
______________________________________________________________________________________________________________________________________________________
Who referred you to our office? Family member Insurance list Coworker Friend Primary Care Doctor Internet search Drove by ZocDoc Demandforce Facebook Other
If "other", please specify

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