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	School Name/Grade:
Primary Doctor:	No Doctor Assigned Dr. Burgess, Lynnette Dr. Hohendorf, Robert Dr. Sanders, Angela	Parents/Spouse:
Date of Injury:

Billing Information

Is The Billing Address the Same?

Title:	First:	Last:	MI:	Suffix:
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:

Primary:

Insurance Information

Insurance Name:	None 21st Century Insurance AAA of Michigan AARP ABP Administration Accordia National Advantra Freedom Aetna US Healthcare Allied Allstate Insurance PIP/Med Pay American Continental American Medical Security American Zurich Insurance ASR Assurant Health Assurant Solutions Auto Owners Ins Co BCBS Federal Employee Program BCBS PPO BCBSM Anthem Blue Care Network Blue Care Network Advantage Blue Cross & Blue Shield MESSA Blue Cross & Blue Shield of Michigan Blue Cross/Blue Shield My Child BlueCross BlueShield of Illinois Bristol West Ins. Group CHAMPVA Cigna Citizens Ins Co Of America Cofinity Cofinity PPO Cofinity/ Sisco Cofinity/NGS Cofinity/Secureone Benefit Administrators Compass Rose Health Plan Conseco Continental Life Corporate Benefit Services of America Coventry Coverys Insurance Services Cypress Benefit Administrators Elco Encompass Insurance Farm Bureau Insurance First Agency First Heath Fremont Mutual Insurance Co. GE Financial Assurance Geico GlobalCare Inc. Golden Rule Great Lakes Employers Assoc Group Marketing Services Harleysville Insurance Hartford Hartford Workers Comp Hastings Mutual Healthsmart Benefits Solutions Humana International SOS Kaiser Permanente Medi-Share Medical Services Admin. Medicare Medicare Advantage Medicare plus Blue Meemic Ins/Cofinity MEGA Mercury Ins. Group Michigan Insurance Company Michigan Miller Mid-west National Life Insurance Company Motorists Insurance Group Mutual Protective/ Medico Life National Association of Letter Carriers NGS Coresource PHP Insurance Company Physician's Care/ ASR health benefits Physicians Care PPO PPOM Premier Health Network Principal Financial Group PPOM Principal Health PPOM Principal Life Ins Co Priority Health HMO/POS Priority Health Medicaid/MI Child Priority Health Medicare Priority Health PPO/EPO/ASO-POS Professional Benefit Services Progressive Car Insurance Pyramid Life Insurance Co. QBE Safeco Secura Insurance Secure Horizons Medicare Plus Sedgwick Insurance Signa Health Care SISCO Standard Life & Accident Ins. Co. State Auto Insurance State Farm Automobile Ins. Co. Surety Thrivent Financial for Lutherans Travelers Insurance Co TriCare UMR Unicare United American Insurance United Healthcare USA Casualty Ins. Washington National Wells Fargo Insurance Services Wolverine Insurance Workman's Compensation
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:	None 21st Century Insurance AAA of Michigan AARP ABP Administration Accordia National Advantra Freedom Aetna US Healthcare Allied Allstate Insurance PIP/Med Pay American Continental American Medical Security American Zurich Insurance ASR Assurant Health Assurant Solutions Auto Owners Ins Co BCBS Federal Employee Program BCBS PPO BCBSM Anthem Blue Care Network Blue Care Network Advantage Blue Cross & Blue Shield MESSA Blue Cross & Blue Shield of Michigan Blue Cross/Blue Shield My Child BlueCross BlueShield of Illinois Bristol West Ins. Group CHAMPVA Cigna Citizens Ins Co Of America Cofinity Cofinity PPO Cofinity/ Sisco Cofinity/NGS Cofinity/Secureone Benefit Administrators Compass Rose Health Plan Conseco Continental Life Corporate Benefit Services of America Coventry Coverys Insurance Services Cypress Benefit Administrators Elco Encompass Insurance Farm Bureau Insurance First Agency First Heath Fremont Mutual Insurance Co. GE Financial Assurance Geico GlobalCare Inc. Golden Rule Great Lakes Employers Assoc Group Marketing Services Harleysville Insurance Hartford Hartford Workers Comp Hastings Mutual Healthsmart Benefits Solutions Humana International SOS Kaiser Permanente Medi-Share Medical Services Admin. Medicare Medicare Advantage Medicare plus Blue Meemic Ins/Cofinity MEGA Mercury Ins. Group Michigan Insurance Company Michigan Miller Mid-west National Life Insurance Company Motorists Insurance Group Mutual Protective/ Medico Life National Association of Letter Carriers NGS Coresource PHP Insurance Company Physician's Care/ ASR health benefits Physicians Care PPO PPOM Premier Health Network Principal Financial Group PPOM Principal Health PPOM Principal Life Ins Co Priority Health HMO/POS Priority Health Medicaid/MI Child Priority Health Medicare Priority Health PPO/EPO/ASO-POS Professional Benefit Services Progressive Car Insurance Pyramid Life Insurance Co. QBE Safeco Secura Insurance Secure Horizons Medicare Plus Sedgwick Insurance Signa Health Care SISCO Standard Life & Accident Ins. Co. State Auto Insurance State Farm Automobile Ins. Co. Surety Thrivent Financial for Lutherans Travelers Insurance Co TriCare UMR Unicare United American Insurance United Healthcare USA Casualty Ins. Washington National Wells Fargo Insurance Services Wolverine Insurance Workman's Compensation
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:	None 21st Century Insurance AAA of Michigan AARP ABP Administration Accordia National Advantra Freedom Aetna US Healthcare Allied Allstate Insurance PIP/Med Pay American Continental American Medical Security American Zurich Insurance ASR Assurant Health Assurant Solutions Auto Owners Ins Co BCBS Federal Employee Program BCBS PPO BCBSM Anthem Blue Care Network Blue Care Network Advantage Blue Cross & Blue Shield MESSA Blue Cross & Blue Shield of Michigan Blue Cross/Blue Shield My Child BlueCross BlueShield of Illinois Bristol West Ins. Group CHAMPVA Cigna Citizens Ins Co Of America Cofinity Cofinity PPO Cofinity/ Sisco Cofinity/NGS Cofinity/Secureone Benefit Administrators Compass Rose Health Plan Conseco Continental Life Corporate Benefit Services of America Coventry Coverys Insurance Services Cypress Benefit Administrators Elco Encompass Insurance Farm Bureau Insurance First Agency First Heath Fremont Mutual Insurance Co. GE Financial Assurance Geico GlobalCare Inc. Golden Rule Great Lakes Employers Assoc Group Marketing Services Harleysville Insurance Hartford Hartford Workers Comp Hastings Mutual Healthsmart Benefits Solutions Humana International SOS Kaiser Permanente Medi-Share Medical Services Admin. Medicare Medicare Advantage Medicare plus Blue Meemic Ins/Cofinity MEGA Mercury Ins. Group Michigan Insurance Company Michigan Miller Mid-west National Life Insurance Company Motorists Insurance Group Mutual Protective/ Medico Life National Association of Letter Carriers NGS Coresource PHP Insurance Company Physician's Care/ ASR health benefits Physicians Care PPO PPOM Premier Health Network Principal Financial Group PPOM Principal Health PPOM Principal Life Ins Co Priority Health HMO/POS Priority Health Medicaid/MI Child Priority Health Medicare Priority Health PPO/EPO/ASO-POS Professional Benefit Services Progressive Car Insurance Pyramid Life Insurance Co. QBE Safeco Secura Insurance Secure Horizons Medicare Plus Sedgwick Insurance Signa Health Care SISCO Standard Life & Accident Ins. Co. State Auto Insurance State Farm Automobile Ins. Co. Surety Thrivent Financial for Lutherans Travelers Insurance Co TriCare UMR Unicare United American Insurance United Healthcare USA Casualty Ins. Washington National Wells Fargo Insurance Services Wolverine Insurance Workman's Compensation
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:

Adult Medical History

ADULT HEALTH/FAMILY HISTORY:

Primary Physcian?		Phone:
Physician's Office Name:
Address:		City/ State/ Zip:
Date of last physical:		How is your general health?	Excellent Good Fair Poor Other

Medications (please List)
For what conditions?

SYSTEMIC DISEASE/CONDITION

Constitutional:	None Fever, weight loss/ gain Other	Who?		Allergic/Immunologic:	None Peanut allergy Latex allergy Lupus Multiple Sclerosis Other	Who?
Integumentary (skin):	None Eczema Other	Who?		Lymphatic/Hematologic:	None Anemia Bleeding Problems Other	Who?
Endocrine:	None Thyroid/ other glands Diabetes Other	Who?		Ear/Nose/Mouth/Throat:	None Allergies/ Hay Fever Sinus Congestion Runny Nose Post-Nasal Drip Chronic Cough Dry Mouth/ Throat Other	Who?
Respiratory:	None Asthma Chronic Bronchitis Emphysema Other	Who?		Vascular/Cardiovascular:	None Heart Disease Arrythmias Vascular Disease High Blood Pressure Other	Who?
Gastrointestinal:	None Diarrhea Irritable Bowel Syndrome Other	Who?		Bones/Joints/Muscles:	None Muscle pain Rheumatoid Arthritis Joint pain Osteoarthritis Fibromyalagia Other	Who?
Neurological:	None Headaches Migraine Seizure Other	Who?		Genitourinary:	None Genitals/ Kidney/ Bladder Other	Who?
Psychiatric:	None Depression Bi-Polar Anxiety Other	Who?

Additional Notes:

VISION HISTORY

Previous Eye Doctor:		Last Exam:
Name of Office:		Phone #:
Address:		City/ Zip:

Do you wear Glasses?	No Yes Other	When do you wear them?		How old?
Do you wear Contact Lenses?	No Yes Other	How often?		What type?

In what ways are you having visual difficulty?

How long have you noticed this difficulty?
Does your job include using a computer terminal? No Yes Other
How do you like to spend your free time?
Are there any activities you would enjoy doing, but must restrict because of your vision?

Additional Notes

If you have experienced any of the following please note when:

Headaches:	Double Vision:
Blurred vision far away:	Eyes hurt or tired:
Blurred vision close up:

If you have noticed any of the following please note when:

Holding reading material close:	Tilting head when reading:
Holding reading material further:	Bothered by light:
Closing one eye:	Inability to see distant objects:
Covering one eye:	Bumping into objects:
Eyes frequently reddened:	Poor general coordination:
Frequent styes:	Excessive eye rubbing:

Get lost in book? unaware peripherally? clumsy? Other:


OCULAR DISEASE/CONDITION

Blindness:	No Yes Other	Who?		Macular Degeneration:	No Yes Other	Who?
Cataract:	No Yes Other	Who?		Lazy Eye/Amblyopia:	No Yes Other	Who?
Eye Turn/Strabismus:	No Yes Other	Who?		Eye Surgery:	No Yes Other	Who?
Glaucoma	No Yes Other	Who?		Eye Injury:	No Yes Other	Who?
Retinal Detachment:	No Yes Other	Who?		Vision Therapy:	No Yes Other	Who?

SOCIAL HISTORY

Do you use tobacco products?	No Yes Other	Type, amount, how long:
Do you drink alcohol?	No Yes Other	Type, amount, how long:
Do you use illegal drugs?	No Yes Other	Type, amount, how long:
Have you ever been exposed to or infected with?	None Gonnorrhea Hepatitis HIV Syphilis Other

Ped Medical Hx

Most Recent Medical Examination:                                                 Has your child been diagnosed as having:

Doctor's Name:
Date:
Results:
Medications Currently Using:
For What Condition?
Is your child generally healthy?

Asthma:	No Yes Other
Hay Fever:	No Yes Other
Allergies:	No Yes Other
ADD or ADHD:	No Yes Other
autism:	No Yes Other

developmental delays:	No Yes Other
cerebral palsy:	No Yes Other
Seizure disorders:	No Yes Other
learning disabilities:	No Yes Other

Has your child had any of the following illness?

ear infections:	No Yes Other	How many/often:		At what Age(s)?
Seizures:	No Yes Other	If yes, please describe:
Surgeries?	No Yes Other	If yes, please describe:
High Fevers?	No Yes Other	How many?		At what Age(s)?
Bad falls?	No Yes Other	If yes, please describe:
Hospitalizations?	No Yes Other	If yes, for what?

BIRTH HISTORY

Full Term Pregnancy?

No Yes Other

If not, how many weeks?

C-Section?

No Yes Other

Forceps?

No Yes Other

Complications of Pregnancy or Birth?

Birthweight:

Adoption (if applicable):

Age adopted:

Location Adopted From:

MEDICAL HISTORY

Does the patient or any family member have:

Heart problems:	No Yes Other	Who?	Lazy eye:	No Yes Other	Who?
High Blood Pressure:	No Yes Other	Who?	Strabismus?	No Yes Other	Who?

Other:


Has your child received or is currently receiving:
Other:

Occupational Therapy:	No Yes Other	With Whom?		How long?
Physical Therapy:	No Yes Other	With Whom?		How long?

Does your child wear glasses? No Yes Other At what age prescribed?


SOCIAL HISTORY:

How does the patient get along with:
Parents? Other adults? Siblings? Classmates?
Does the child make friends easily? No Yes Other How does the child play with others?

In a few words, describe the patient as:
An infant:
A toddler:
Currently:
Do you have any other social concerns for the patient? No Yes Other

Submit Data