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	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Jennifer Khanh Dr. Chris Eugenio Dr. Lan Nguyen	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 Vision

Insurance Information

Insurance Name:	None Aetna Ameritas BCBS Texas CIGNA Community Eye Care Envolve Eyemed Eyetopia Group & Pension Administrators Humana Humana Medicare Advantage ManhattanLife Assurance Medicare Meritain Health MES Vision Miscellaneous Insurers Nat'l Vision Administrators NMI NVI PHCS Premier Eye Care Scott & White Health Plan Superior Vision Services TML Intergovemmental Employee Benefits Tricare Tricare East UMR United Healthcare Versant Health Vision Benefits of America Vision Care Advantage Vision Care Direct VSP Access VSP Access Indemnity VSP Advantage VSP appt VSP Choice Exam+ VSP Choice Plan VSP Computer Vision Care VSP Exam Plus VSP Signature VSP Vision Savings Pass Wellmed - Humana Wellmed - PHC Wellmed - UHC
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 Vision

Insurance Information

Insurance Name:	None Aetna Ameritas BCBS Texas CIGNA Community Eye Care Envolve Eyemed Eyetopia Group & Pension Administrators Humana Humana Medicare Advantage ManhattanLife Assurance Medicare Meritain Health MES Vision Miscellaneous Insurers Nat'l Vision Administrators NMI NVI PHCS Premier Eye Care Scott & White Health Plan Superior Vision Services TML Intergovemmental Employee Benefits Tricare Tricare East UMR United Healthcare Versant Health Vision Benefits of America Vision Care Advantage Vision Care Direct VSP Access VSP Access Indemnity VSP Advantage VSP appt VSP Choice Exam+ VSP Choice Plan VSP Computer Vision Care VSP Exam Plus VSP Signature VSP Vision Savings Pass Wellmed - Humana Wellmed - PHC Wellmed - UHC
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 Information

Insurance Name:	None Aetna Ameritas BCBS Texas CIGNA Community Eye Care Envolve Eyemed Eyetopia Group & Pension Administrators Humana Humana Medicare Advantage ManhattanLife Assurance Medicare Meritain Health MES Vision Miscellaneous Insurers Nat'l Vision Administrators NMI NVI PHCS Premier Eye Care Scott & White Health Plan Superior Vision Services TML Intergovemmental Employee Benefits Tricare Tricare East UMR United Healthcare Versant Health Vision Benefits of America Vision Care Advantage Vision Care Direct VSP Access VSP Access Indemnity VSP Advantage VSP appt VSP Choice Exam+ VSP Choice Plan VSP Computer Vision Care VSP Exam Plus VSP Signature VSP Vision Savings Pass Wellmed - Humana Wellmed - PHC Wellmed - UHC
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 Information

Insurance Name:	None Aetna Ameritas BCBS Texas CIGNA Community Eye Care Envolve Eyemed Eyetopia Group & Pension Administrators Humana Humana Medicare Advantage ManhattanLife Assurance Medicare Meritain Health MES Vision Miscellaneous Insurers Nat'l Vision Administrators NMI NVI PHCS Premier Eye Care Scott & White Health Plan Superior Vision Services TML Intergovemmental Employee Benefits Tricare Tricare East UMR United Healthcare Versant Health Vision Benefits of America Vision Care Advantage Vision Care Direct VSP Access VSP Access Indemnity VSP Advantage VSP appt VSP Choice Exam+ VSP Choice Plan VSP Computer Vision Care VSP Exam Plus VSP Signature VSP Vision Savings Pass Wellmed - Humana Wellmed - PHC Wellmed - UHC
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:

Other

Insurance Information

Insurance Name:	None Aetna Ameritas BCBS Texas CIGNA Community Eye Care Envolve Eyemed Eyetopia Group & Pension Administrators Humana Humana Medicare Advantage ManhattanLife Assurance Medicare Meritain Health MES Vision Miscellaneous Insurers Nat'l Vision Administrators NMI NVI PHCS Premier Eye Care Scott & White Health Plan Superior Vision Services TML Intergovemmental Employee Benefits Tricare Tricare East UMR United Healthcare Versant Health Vision Benefits of America Vision Care Advantage Vision Care Direct VSP Access VSP Access Indemnity VSP Advantage VSP appt VSP Choice Exam+ VSP Choice Plan VSP Computer Vision Care VSP Exam Plus VSP Signature VSP Vision Savings Pass Wellmed - Humana Wellmed - PHC Wellmed - UHC
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:

Chief Complaint

Please choose from the menu options or select "OTHER" to type in multiple choices or your own text. Thank you!

Reason for Visit

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 annual doctor directed diabetic eye exam failed screening at school Other
Secondary Complaints:
Notes:

Review of Ocular System

Ocular History:
Eye Meds:
Last Eye Exam:	1 year 2 years 3 years Other         Doctor: Gauer Doesn't Remember Never Seely Wilson Gray Weston Tronnes Woodruff Stanley Leech Goodwin Palm Moran 'Walmart doctor' Lenscrafters VisionWorks/Binyon Kitchens Other

Primary Vision Correction:

None Glasses-Full Time RGPs Readers only Soft Contact Lenses Other

Back up specs?

Yes No Other

Planning to get new glasses?

Yes No Other

Brand of contact lenses worn in past:	None RGP Air Optix Purevision Oasys Proclear Biofinity Other	Wear Time:	EW FT PT Rarely Other	Cleaner:	Biotrue Optifree Clear Care Boston Renu Pure and Moist/Alcon ClearCare Other
Disposal:	2 weeks monthly daily weekly yearly Other	Current contact lenses:	1 mon 2 mon 2 wks Other

Family Ocular History

Glaucoma:	No Parents Sibling Grandparent Other	Cataracts:	No Parents Siblings Grandparent Other	Macular Degeneration:	No Parents Siblings Grandparent Other
Retinal Detachment:	No Parents Siblings Grandparent Other	Crossed / Lazy:	No Parents Siblings Grandparent Other

Miscellaneous

Race:	American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Other       Ethnicity: Non Hispanic or Latino Hispanic or Latino Other       Preferred Language: English French German Spanish Other
NOTES:

Medical History

Please choose from the menu options or select "OTHER" to type in multiple choices or your own text. Thank you!

General Information

Problems:

Good health Arthritis Asthma Diabetes HBP Headaches Heart Condition HX Of Drug/Alcohol Abuse Inflammatory Bowel Disease Smoking Seizure Disorder Thyroid Disease Preg "Now" Nursing Diagnosed As HIV+ Other

Diabetes HBP Heart disease Cancer Arthritis Lupus Kidney Thyroid Back Problems Other

Athritis Diabetes HBP Heart Disease Cancer Lupus Kidney Disease Thyroid Disease Back Problems Other

Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Thyroid Back Problems Other

Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Thyroid Disease Back Problems Other

Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Disease Thyroid Back Problems Other

Injuries, Surgeries, Hospitalization

None Cataract Surgery Retina Surgery Other

Pregnant Or Nursing:

No Yes Unsure Other

Recent Tetanus Shot:

Yes No Other

Notes:

Primary Care Physcian:

Doesn't Have One Doesn't Remember None Other

Last Visit:

1 week 1 month 3 months 6 months 1 year 2 years Other

Reason For Visit:

Check up Annual Other

Patient Medical History

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

Medications:                     No current medications

Drug Allergies:       No known drug allergies

Over The Counter Meds: None Asprin Acetomenophin Ibuprofen Other             Vitamins: None A E C Zinc Xanten Lutein Other

Social History

Occupation:

Student Police officer Teacher Nurse Salesman Firefighter Engineer Other

Hobbies:

Astronomy Art Baseball Boating Basketball Cooking Crafts Dancing Diving Football Fishing Golf Gardening Horseback Riding Hunting Models Needlepoint None Painting Photography Piano Reading Running Roller Blading Softball Sewing Skiing Soccer Swimming Tennis Video Games Woodworking Other

Smoking Status:	Never Smoker Current every day smoker Current some day smoker Former smoker Smoker, currernt status unknown Unknown if ever smoked Other	Type:	None Cigaretts Chewing Tobacco Other	How Long:
Alcohol:	No Yes Occasionally Socially Other	Type:	None Beer Wine Hard Liquor Other	How Long:
Illegal Drugs:	No Yes Other	Type:		How Long:
STD:	None Gonorrhea Syphilis Hepatitis HIV TB Other

Review of Systems

Please choose from the menu options or select "OTHER" to type in multiple choices or your own text. Thank you!

Review of Systems

GENERAL: Fever, weight loss, weight gain, fatigue?	None Other
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat	None Allergies Sinus Problems Chronic Cough Dry Throat / Mouth Hard of Hearing Other
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease	None Vascular Disease HBP Heart Surgery Other
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD	None Asthma Bronchitis Emphysema COPD Other
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence	None painful urination frequent urination impotence yellow jaundice Other
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury	None joint pain stiffness swelling cramps arthritis Other
SKIN: growths, rashes, acne	None pimples, warts growths rash Other
NEUROLOGICAL: Headaches, migraines, seizures	None numbness, paralysis headache seizures migraines Other
PSYCHIATRIC: Depression, Anxiety, Insomnia	None anxiety depression insomnia Other
ENDORCRINE: Thyroid, Diabetes	None diabetes hypothyroid hyperthoyroid Other
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems	None bleeding cholestrolemia anemia Other
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Lupus	None sneezing swelling redness itching hives lupus Other
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux	None Diarrhea Constipation Ulcer Acid Reflux Other

COVID Questionnaire

1. Have you tested POSTIVE for COVID-19 or have you been in contact with anyone who has tested POSITIVE for COVID-19?

Yes No      If so, how long ago?

2. Are you coughing?

Yes No

3. Are you experiencing shortness of breath?

Yes No

4. Do you have red eye(s)?

Yes No

IF PATIENT APPEARS ILL, they should consult their PCP first unless they are experiencing emergency warning signs. If they develop any emergency warning signs for COVID-19, they should seek medical attention immediately.

        a. Trouble breathing
        b. Persistent pain or pressure in the chest
        c. Bluish lips or face

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