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? - All No

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? - All No

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? - All No

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)? - All No

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

Signatures and Submit Data

Contact Lens Compliance

Click here to read the Compliance form

I have read and understood all of the above instructions

Electronic Signature:

Contact Lens Fees

Click here to read the Contact Lens fees

I would like to have a contact lens evaluation today.

Initials

I do not want a contact lens evaluation today and I am aware that without it I will not get a prescripton for contact lenses.

Initials

Patient name: Date:

Electronic Signature of Responsible Party:

Notice of Franklin Family Eyecare Policies Relating to Patient Privacy

Click here to read the Privacy Policies

I, acknowledge that I have received a copy of the Patient Privacy Polcies of Franklin Family Eyecare

Electronic Signature: Date:

Optomap

Click here to read Optomap Information

I would like more information on the Optomap Retinal Imaging
I DO want Optomap retinal imagin and I understand that I am responsible for the $40.
I DO NOT want the Optomap retinal Imaging and prefer to have the dialation drops.

Electronic Signature: Date: