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:

Health Insurance

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:

Vision Plan

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:

Supplemental Ins

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

Chief Complaint

             
Location:   Severity:   Quality:   Duration:
     

Secondary Complaints:

Review of Ocular System

Ocular History:   Eye Meds:   Last Eye Exam:   Doctor:    
         
                 
Glaucoma:   Cataracts:   Macular Degen:   Retinal Detach:   Crossed / Lazy:
       
                 
Primary Vision Correction:       Back up specs?    
         
                 
Type of CLs worn in past:   Wear Time:   Cleaner:   Disposal:
     
                 
Race:   Ethnicity:   Preferred Language:
   

Patient Medical History

Known Medical Issues/Problems:            
       
                 
Injuries, Surgeries, Hospitalization      
             
Pregnant Or Nursing:   Recent Tetanus Shot:
     
                 
Notes:                
       
                 
Primary Care Physcian:   Last Visit:   Reason For Visit:    
       
                 
Current Medications:   No current meds   Over The Counter Meds:   Vitamins:
             

Family Medical History

           
                 
Mother   Father   Siblings   Grandparents   Other
       
                 

Social History

Occupation:       Hobbies:        
             
                 
Smoking Status:   Type:   How Long:    
       
                 
Alcohol:       Type:   How Long:    
           
                 
Illegal Drugs:       Type:   How Long:   STD:
         
                 
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  
     
ENDORCRINE: Thyroid, Diabetes  
     
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems  
     
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus  
     
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux  
     
     

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