New Patient Form

Demographics

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

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	Single Married Separated Divorced Widowed Unknown	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Barajas, OD, Juan	Misc/Guardian

Ethnicity:  Hispanic or Latino Hispanic or Latino Unknown Patient Declined to Specify   Race: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Patient Declined to Specify Other

Billing Information

Is The Billing Address the Same?

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

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:

Medical History

DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?

Eyes			General			Cardiovascular
Eye Pain/Soreness:	Yes	No	Fever:	Yes	No	Heart Problems:	Yes	No
Fatigue/Tired Eyes:	Yes	No	Weight Loss/Gain:	Yes	No	Congestive Heart Failure:	Yes	No
Foreign Body Sensation:	Yes	No				High Blood Pressure:	Yes	No
Dryness/Gritty Feeling:	Yes	No	Skin			High Cholesterol:	Yes	No
Redness:	Yes	No	Metal Allergies:	Yes	No	Stroke:	Yes	No
Burning:	Yes	No
Itching:	Yes	No	Ear/Nose/Throat			Gastrointestinal
Excess Watering:	Yes	No	Allergies/Hay Fever:	Yes	No	Acid Reflux:	Yes	No
Mucous Discharge:	Yes	No	Sinus Infections:	Yes	No	Intestinal Problems:	Yes	No
Chronic Eye Infection:	Yes	No	Hearing Loss:	Yes	No	Liver Problems:	Yes	No
Squinting:	Yes	No	Rosacea:	Yes	No
Glare/Light Sensitivity:	Yes	No				Endocrine
Halos:	Yes	No	Respiratory			Thyroid/Other Glands:	Yes	No
Double Vision:	Yes	No	Asthma:	Yes	No	Diabetes:	Yes	No
Loss of Vision:	Yes	No	Chronic Bronchitis:	Yes	No
Blurred Vision:	Yes	No	Emphysema:	Yes	No	Genitourinary
Flashes:	Yes	No				Genital/Kidney/Bladder Problems:	Yes	No
Floaters:	Yes	No	Lymph/Blood
			Anemia:	Yes	No	Psychiatric Conditions:	Yes	No
Neurological			Bleeding:	Yes	No	Immune System Conditions:	Yes	No
Headaches:	Yes	No
Migraines:	Yes	No	Bones/Joints/Muscles
Seizures:	Yes	No	Rheumatoid Arthritis:	Yes	No
Alzheimer's:	Yes	No	Muscle/Joint Pain:	Yes	No
Parkinson's:	Yes	No

PATIENT MEDICAL HISTORY

Do you have any of the following medical conditions?

Good health Acid Reflux Allergies Anemia Arthritis Asthma Diabetes Drug/Alcohol Abuse HBP Headaches Hearing loss Heart Condition HIV + hypercholesterolemia Hypertension Inflammatory Bowel Disease Migraines Muscle/Joint Pain Nursing Preg "Now" Seizure Disorder Sinusitis Smoking Thyroid Disease Other Other	Diabetes HBP Heart disease Cancer Arthritis Lupus Kidney Thyroid Back Problems Other	Athritis Diabetes HBP Heart Disease Cancer Lupus Kidney Disease Thyroid Disease Back Problems Other
Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Thyroid Back Problems Other	Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Thyroid Disease Back Problems Other	Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Disease Thyroid Back Problems Other

Please list any Injuries, Surgeries, Hospitalization

Pregnant Or Nursing: No Yes Unsure Recent Tetanus Shot: Yes No

Notes:

Primary Care Physician:

Last Visit: 1 week 1 month 3 months 6 months 1 year 2 years

Reason For Visit: Annual Physical Visit for a specific problem Check up    List any Vitamins you take:

Please list any over the Counter medications:

Please list your current Prescription Medications:

Occupation: Hobbies:

Smoking Status: Never Smoker Current every day smoker Current some day smoker Former smoker Smoker, currernt status unknown Unknown if ever smoked Type: None Cigarettes Cigars Pipes Chewing Tobacco How Long:

Alcohol: No Yes Occasionally Socially Type: None Beer Wine Hard Liquor How Long:

Illegal Drugs: No Yes Type: How Long: STD: None Gonorrhea Syphilis Hepatitis HIV TB

FAMILY MEDICAL HISTORY

Do you have a history of any of the following in your family?

Blindness:	Yes	No	Relationship to You:
Crossed Eyes:	Yes	No	Relationship to You:
Cataracts:	Yes	No	Relationship to You:
Glaucoma:	Yes	No	Relationship to You:
Mac Degen:	Yes	No	Relationship to You:
Cancer:	Yes	No	Relationship to You:
Diabetes:	Yes	No	Relationship to You:
Heart Disease:	Yes	No	Relationship to You:
High BP:	Yes	No	Relationship to You:
Stroke:	Yes	No	Relationship to You:
Thyroid Disease:	Yes	No	Relationship to You:

PATIENT OCULAR HISTORY

Do you use eye drops on a regular basis? If so, what and how often?


Do you use eye medications on a regular basis? If so, what and how often?


Do you have any:

Eye Injuries (Foreign Objects, Black eye, etc.):	Yes	No
Eye Disease (Cataracts, Glaucoma, Pterygium, etc.):	Yes	No
Eye Surgeries (Cataracts, Vision Correction, etc.):	Yes	No

If yes to any of the above, please explain:

Have you ever worn soft contacts?:	Yes	No
Have you ever worn hard contacts?:	Yes	No

Last Eye Doctor: Last Eye Exam: 1 year 2 years 3 years over 3 years  

Primary Vision Correction:  None Glasses-Full Time Glasses-Readers Only Contacts - Soft RGPs PMMA  Planning to get new glasses? Yes No  Back up specs? Yes No

Type of CLs worn in past: None Disposable Conventional Colored RGP PMMA  Wear Time: 8 - 10 Hours All day Occ. Overnight Extended Cleaner: Optifree Clear Care Boston Renu Disposal: 2 weeks monthly daily weekly yearly

FAMILY OCULAR HISTORY

Glaucoma: No Parents Sibling Grandparent Crossed / Lazy: No Parents Siblings Grandparent Retinal Detach: No Parents Siblings Grandparent Macular Degeneration: No Parents Siblings Grandparent Cataracts: No Parents Siblings Grandparent

Medical Insurance

Insurance Information

Insurance Name:	None New Insurance AARP Aetna Aetna Medicare Advantage American National Life Insurance Ameritas Bankers Fidelity BCBS of TX Christian Fidelity Cigna Cigna Health Springs Continental General Insurance Co. Coventry Health Care CSI - Central States Indemnity Department of Assistive and Rehabilitative Services Firstcare Gilsbar Health Net Humana IMG Loyal American Life Insurance Co. Mail Handlers Benefit Plan Medicare Mutual of Omaha National Telecommunications Cooperative New Era Life Insurance Company Old Surety Life Omaha Insurance Company OUT OF STATE Physicans Mutual Principal Life Insurance Company Reserve National Insurance Company State Farm Texas Agriculture Benefits Administrators TransAmerica Life Insurance Company Tricare U.S. Department of Veteran Affairs UMR United American Insurance Company United Healthcare Universal Fidelity Life Wellcare Pharmacy
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 Plan

Insurance Information

Insurance Name:	None Ameritas Eyemed Eyetopia Firstcare MES Vision VSP VSP Access Plan VSP Choice VSP Exam+ Plan VSP Exam+ Plan w/Allowances VSP Signature
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:

NOTES: 

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