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:

Medical History

Location:
Severity:
Quality:
Duration:
Timing:
Context:
Modifying:
Associated:
Secondary Complaints:
Ocular History
Eye Meds:
Last Eye Exam:
Doctor:
Glaucoma:
Cataracts:
Macular Degen:
Retinal Detach:
Crossed / Lazy:
Primary Vision Correction:
Back up specs?
Planning to get new glasses?
Type of CLs worn in past:
Wear Time:
Cleaner:
Disposal:
Race:
Ethnicity:
Preferred Language:
NOTES:
Notes:
fmh2
fmh3
fmh4
fmh5
fmh6
Occupation:
Hobbies:
Smoking Status:
Type:
How Long:
Alcohol:
Type:
How Long:
Illegal Drugs:
Type:
How Long:
STD:
Problems:
Current Medications:
Medication Allergies:
Reason For Visit:
Last Visit:
Primary Care Physcian:
Notes:
Pregnant Or Nursing:
Injuries, Surgeries, Hospitalization
medhx6
medhx5
medhx4
medhx3
medhx2
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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