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:

Vision-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:

Vision-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:td>Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History



Chief Complaint (please explain the reason for your visit):


Duration: Quality: Severity: Location:
Associated: Modifying: Context: Timing:


Secondary Complaints


Primary Care Physician:
Pregnant Or Nursing:


Medications (Please list any medications you're currently taking below): No Current Medications
Drug Allergies: No Known Drug Allergies

Injuries, Surgeries, Hospitalizations:


FAMILY MEDICAL HISTORY: Diabetes, HBP, Heart Dz, Cancer, Athritis, Lupus, Kidney, Thyroid, Other


OCULAR HISTORY

Last Comprehensive: Doctor:

Ocular History (ex: cataracts, macular degeneration, glaucoma, retinal detachment, crossed/lazy eye etc.):

Ocular Surgeries:


Ocular Medications (Please list any ocular medications you're currently taking below):


FAMILY OCULAR HISTORY

Glaucoma: Macular Degen: Cataracts: Retinal Detach: Crossed / Lazy:


SOCIAL HISTORY

Hobbies:

Smoking Status: Type:
Alcohol Use: Type:
Illegal Drugs: Type:

Race: Ethnicity: Preferred Language:


Review of Systems


Please select an option from each menu, and select "Other" where needed to type in an option not included in the drop down. Thank you!
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
ENDOCRINE: Thyroid, Diabetes
BLOOD/LYMPH: Anemia, Cholesterol, Bleeding Problems
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Acid Reflux
STD History:
Notes:

Submit Data

After Completing All Forms Submit Data on Final Tab