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 Eye Doctor	No Doctor Assigned Dr. Bardash, John Dr. Puzzo, Alfonso	Misc/Guardian

How did you hear about us?

Yelp Google Search Post card Vision Insurance Medical Insurance Email Family/Friend Website Phone Call Doctor Referral Established Patient Promotional Offer Dr. Bardash Radio News Paper TV Location Sign

Vision Insurance

Insurance Information

Insurance Name:	None Aetna Medical Aetna Vision Cigna - GWH - Greatwest Cigna Medical EyeMed Humana Medical Humana Vision, Vision Care Plan Medicaid Medicare Other Rocky Mountain UFCW Unions & Employers Health Benefits Superior Vision Tri-care for Life Tri-Care West Region UMR United Health Care Medical VA (Veterans Choice Program) VACAA Vision Service Plan
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Is the primary address the same as the patients?

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical Insurance

Insurance Information

Insurance Name:	None Aetna Medical Aetna Vision Cigna - GWH - Greatwest Cigna Medical EyeMed Humana Medical Humana Vision, Vision Care Plan Medicaid Medicare Other Rocky Mountain UFCW Unions & Employers Health Benefits Superior Vision Tri-care for Life Tri-Care West Region UMR United Health Care Medical VA (Veterans Choice Program) VACAA Vision Service Plan
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Is the primary address the same as the patients?

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Eye History

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

Reason for Visit:

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 blurrred vision Other

Ocular History

None Burning, Stinging Amblyopia Eye Injuries Eye Surgery Flashes Of Light Floaters Strabismus Cataracts Glaucoma Retinal Disorders Itching Other

Eye Meds:

None Cromolyn NA 4% Visine Patanol Xalatan Travatan rewetting drops Elestat Vigamox Alphagan Refresh Theratears Genteal Pred Forte Lotemax Alrex Systane Blink Other

Last Eye Exam:

Doctor:

Glaucoma:

No Mother Father Sibling Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Other

Cataracts:

No Mother Father Sibling Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Other

Macular Degen:

No Mother Father Sibling Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Other

Retinal Detach:

No Mother Father Sibling Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Other

Crossed / Lazy:

No Mother Father Sibling Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Other

Primary Vision Correction:

None Glasses-Full Time Glasses-Readers Only Contacts - Soft RGPs PMMA Other

Back up specs?

Yes No

Planning to get new glasses?

Yes No

Type of CLs worn in past:

None Disposable Conventional Colored RGP PMMA Other

Wear Time:

8 - 10 Hours All day Occ. Overnight Extended Other

Cleaner:

Optifree Clear Care Boston Renu Other

Disposal:

2 weeks monthly daily weekly yearly Other

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:

Review of Symptoms

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

Do you have any of these symptoms? (Symptoms that your currently have and are taking medication for.)

GENERAL: Fever, weight loss, weight gain, fatigue?

None Fever Fatigue weight gain weight loss 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, Allergy Shots, Lupus

None sneezing swelling redness itching hives lupus Other

GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

None Diarrhea Constipation Ulcer Acid Reflux Other

Medical History

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

Medical Condition and Medicine Taken: Medical Condition and Medicine Taken 2:

Medical Condition and Medicine Taken 3:

Medical Condition and Medicine Taken 4:

Medical Condition and Medicine Taken 5:

Medical Condition and Medicine Taken 6:

Injuries, Surgeries, Hospitalization

Pregnant Or Nursing:

No Yes Unsure

Recent Tetanus Shot:

Yes No Other

Notes:

Primary Care Physician:

Last Visit:

Reason For Last Visit:

Check up Annual Other

No current meds NKDA

OTC:

None Asprin Acetomenophin Ibuprofen Other

Vitamins:

None A Omega 3 Flax Seed Multi Vitamin B I Caps E C Zinc Xanten Lutein Calcium Other

Family Medical History:

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

Family Medical History 2

Family Medical History 3

Family Medical History 4

Family Medical History 5

Family Medical History 6

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

Type:

None Cigarettes Chewing Tobacco Other

How Long:

Alcohol:

No Yes Occasionally Socially Other

Type:

None Beer Wine Hard Liquor Other

How Long:

Illegal/Legal Drugs:

No Yes Other

Type:

How Long:

Infectious Disease:

None Gonorrhea Syphilis Hepatitis HIV TB Other

Submit Data