New Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
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:

Insurance 1

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:
Employer/School:

Insurance 2

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:
Employer/School:

Insurance 3

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:
Employer/School:

Medical History

Occupation:
Hobbies:
Reason for Visit
Any Unusual symptoms ?
Last Eye Exam:
Doctor:
Primary Vision Correction:
Type of CL
Do you sleep in your contacts?
Do you swim w/ CL's?
Prior Eye Injury/ Eye Surgery?
Eye Meds:
CURRENT MEDICAL CONDITIONS:
Blood or heart problems
Thyroid, Diabetes
Allergies, Sinus, Cough
Asthma, Bronchitis, Emphysema
Arthritis, joint pain
Diarrhea, Constipation, Ulcer, Reflux
Infection, Inflammation, Pain
Headaches, Numb, Dizzy, Seizures
Rheumatoid arthritis, HIV/AIDS, Lupus, Sarcoidosis
Depression, Anxiety, Insomnia
Skin Growths, Rashes, or Acne
Fever, weight loss/gain, fatigue?
Anemia or blood disorders
Previous Injuries / Surgeries :
GP:
Last Visit:
Are you Pregnant or Nursing?
MEDICATIONS:
Drug Allergies:
OTC
Vitamins
Alcohol Use
Tobacco Use
Mental Status
Illegal Drugs?
FAMILY HISTORY:
Cataracts
Macular Degeneration
Glaucoma
Retinal Detachment
Crossed / Lazy Eye
Blindness
Diabetes
Other:
HTN
Cancer
OTHER: