New Patient Form

Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Address:
City:		State/ZipCode	IN AL AK AZ AR CA CO CT DE DC FL GA HI ID IL 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 TX 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	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Rigsby, OD, Carole Richard R Rigsby, OD	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Address

City	State	ZipCode
	IN AL AK AZ AR CA CO CT DE DC FL GA HI ID IL 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 TX UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Medical Primary

Insurance Information

Insurance Name:	None Aetna Alamo Barter Corp BCBS Benefit Planners Boone-Chapman Care Credit Cigna EyeMed Vision Eyetopia GEHA Humana Access PPO Humana PPO Medicaid/Nat.heritage Ins Co Medicare Part B MHBP New Insurance New Insurance Other PHCS Principle Financial Southwest Tx. Outfitters Spectera Speedway Erection Superior Vision Services Texas Tru Choice Tricare for Life Tricare Prime UMR United Health Care United of Omaha Vision Care Vision Service Plan VSP, Medical Services Claim W.S. Steel Erection W.S. Steel Structures
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:	None Aetna Alamo Barter Corp BCBS Benefit Planners Boone-Chapman Care Credit Cigna EyeMed Vision Eyetopia GEHA Humana Access PPO Humana PPO Medicaid/Nat.heritage Ins Co Medicare Part B MHBP New Insurance New Insurance Other PHCS Principle Financial Southwest Tx. Outfitters Spectera Speedway Erection Superior Vision Services Texas Tru Choice Tricare for Life Tricare Prime UMR United Health Care United of Omaha Vision Care Vision Service Plan VSP, Medical Services Claim W.S. Steel Erection W.S. Steel Structures
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 Secondary

Insurance Information

Insurance Name:	None Aetna Alamo Barter Corp BCBS Benefit Planners Boone-Chapman Care Credit Cigna EyeMed Vision Eyetopia GEHA Humana Access PPO Humana PPO Medicaid/Nat.heritage Ins Co Medicare Part B MHBP New Insurance New Insurance Other PHCS Principle Financial Southwest Tx. Outfitters Spectera Speedway Erection Superior Vision Services Texas Tru Choice Tricare for Life Tricare Prime UMR United Health Care United of Omaha Vision Care Vision Service Plan VSP, Medical Services Claim W.S. Steel Erection W.S. Steel Structures
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:	None Aetna Alamo Barter Corp BCBS Benefit Planners Boone-Chapman Care Credit Cigna EyeMed Vision Eyetopia GEHA Humana Access PPO Humana PPO Medicaid/Nat.heritage Ins Co Medicare Part B MHBP New Insurance New Insurance Other PHCS Principle Financial Southwest Tx. Outfitters Spectera Speedway Erection Superior Vision Services Texas Tru Choice Tricare for Life Tricare Prime UMR United Health Care United of Omaha Vision Care Vision Service Plan VSP, Medical Services Claim W.S. Steel Erection W.S. Steel Structures
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

Medical History:
Family Doctor's Name: Family Doctor's Phone #:
Last Eye Exam: Last Medical Physical:


Females: are you Pregnant/Nursing? No Yes
Do you drive? Yes No
Do you have visual difficulty driving? No Yes
Do you use alcohol products? No Yes
Do you use illicit drugs? No Yes
Have you been exposed to any infectious disease? No Yes
Smoking Status Unknown Never Smoker Current, every day smoker Current, some day smoker Former Smoker Smoker, current status unknown


Do you have Diabetes? No Yes for how many years? What medication do you use?

Diabeties Doctor (endrocrinologist): Endrocrinologist Phone Number:

Do you have Hypertension? Yes No for how many years? What medication do you use?
Do you have Cholesterol Problems? Yes No for how many years? What medication do you use?

Please list any medications you are allergic to:


Please list any and all medications you are currently taking, including Over the Counter, Homeopathic, Birth Control, or Remedies:


Please list and date all major injuries, surgeries, and hospitalizations you have had:

Review of Systems (ROS):
Do you currently have any problems with:
No Yes fever weight loss appetite Constitutional (fever, weight loss, appetite):
No Yes skin conditions disorders Integumentary (skin conditions/disorders):
No Yes headaches migraines seizures Neurological (headaches, migraines, seizures):
No Yes thyroid diabetes Endocrine (thyroid, diabetes):
No Yes allergies sinus cough dry mouth Ears, Nose, Throat (allergies, sinus, cough, dry mouth):
No Yes asthma emphysema bronchitis Respiratory (asthma, emphysema, bronchitis):
No Yes hypertension stroke heart pain Vascular (hypertension, stroke, heart pain):
Yes No diarrea constipation Gastrointestinal (diarrea, constipation):
No Yes kidney bladder genitals Genitourinary (kidney, bladder, genitals):
No Yes rheumatoid arthritis muscle pain Bones,/Joints (rheumatoid arthritis, muscle pain):
No Yes lymphatric hematologic Lymphatric/Hematologic):
No Yes allergies Lupus Autoimmune disorder Allergic/Immunologic (allergies, bleeding):
No Yes depression anxiety Bipolar OCD Psychiatric (depression, anxiety):

Ocular Review of Systems: do you have or have had:
No Right Eye Left Eye Both Eyes Sudden vision loss
No Right Eye Left Eye Both Eyes Blurred vision
No Right Eye Left Eye Both Eyes Loss of side vision
No Right Eye Left Eye Both Eyes Double vision
No Right Eye Left Eye Both Eyes Floaters
No Right Eye Left Eye Both Eyes Flashes of light
No Right Eye Left Eye Both Eyes Mucus discharge
No Right Eye Left Eye Both Eyes Redness
No Right Eye Left Eye Both Eyes Gritty feeling/dryness
No Right Eye Left Eye Both Eyes Itching/burning
No Right Eye Left Eye Both Eyes Tearing/watery
No Right Eye Left Eye Both Eyes Glare/light sensitivity
No Right Eye Left Eye Both Eyes Eye pain/discomfort
No Right Eye Left Eye Both Eyes Haloes at night

Do you have a family history of:
No Parent Grandparent Sibling Blindness
No Parent Grandparent Sibling Cataracts
No Parent Grandparent Sibling Glaucoma
No Parent Grandparent Sibling Macular Degeneration
No Parent Grandparent Sibling Retinal Disease
No Parent Grandparent Sibling Arthritis
No Parent Grandparent Sibling Cancer
No Parent Grandparent Sibling Diabetes
No Parent Grandparent Sibling High Blood Pressure
No Parent Grandparent Sibling Heart Disease
No Parent Grandparent Sibling Kidney Disease
No Parent Grandparent Sibling Thyroid Disease

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