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:

Primary

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:

Secondary

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:

Tertiary

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:

Patient Medical History


VISUAL HISTORY:
Do you currently wear glasses?:
Do you currently, or have you ever worn contact lenses?: Soft Rigid Gas Permeable How many years have you worn contact lenses?:
New patients only, please list your current contact lens brand & prescription, if known:
If previous wearer, why did you stop wearing contact lenses?


OCULAR HISTORY

Do you have a history of any of the following eye conditions?   Are you currently experiencing any of the following symptoms?:
Color Blindness  Glaucoma               Loss of Vision  Burning 
Cataracts  Amblyopia or Lazy Eye   Blurred Vision Near  Tearing 
Retinal Detachment  Strabismus or Eye Turn    Blurred Vision Distance Glare/Light Sensitivity 
Macular Degeneration Other:   Fluctuating Vision  Frequent styes 
      Loss of Side Vision  Tired Eyes 
      Double Vision  Headaches 
      Dryness  Eye Pain 
      Mocous Discharge  Floaters 
      Redness  Flashing lights 
      Sandy/Gritty feeling  Halos around lights 
      Itching   Other (Please describe)



    

 
   
 
  
 



 

 

 

 

 

Please list all ocular medications used (prescription or over-the-counter):

How often used?:
List all eye injuries you have had:
List all eye surgeries you have had:
 

MEDICAL HISTORY / REVIEW OF SYSTEMS:

Do you have any systemic health problems, (such as high blood pressure, diabetes, high cholesterol, etc.)?

Please list any medications currently taking (prescription or over-the-counter):

Are you allergic to any medications? (please list):
When was your last visit with a primary care physician?
               Physician's Name: 
 

Do you have problems with any of the following?

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
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux
SKIN: growths, rashes, acne
PSYCHIATRIC: Depression, Anxiety, Insomnia
ENDOCRINE: Thyroid, Diabetes
BLOOD/LYMPH: Anemia, choles  terol, bleeding problems
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Lupus
MUSCLES, BONES, JOINTS: Athritis, Joint Pains, Head or Neck Injury
NEUROLOGICAL: Headaches, migraines, seizures
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence

 

 

 

 

 

 



 

 

 


Notes

Weight   Height:
Are you pregnant or nursing?

Family Medical History



FAMILY HISTORYFamily history is unknown/adopted


Any history of the following in any family members (parents, grandparents, siblings, children)?
 

  YES NO RELATIONSHIP TO PATIENT   YES NO RELATIONSHIP TO PATIENT
Blindness Retinal Detachment
Glaucoma Cancer
Diabetes High Blood Pressure
Cataracts Stroke
Macular Degeneration Thyroid Disease
Lazy Eye (Amblyopia) Heart Disease
Eye turn (Strabismus) Other Inherited Disease
Color Blindness        

 

 

 

 

 

 

 

Notes:


SOCIAL HISTORY (confidential)

How often do you smoke/use tobacco products?       How often do you consume alcohol?:
Occupation:     Employer: 
If a new patient, who referred you to our office?
           If not referred, how did you hear about Baxter Eye Care?

Submit Data

After Completing All Forms Submit Data on Final Tab