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
Height: Ft. In. Weight:

Preferred Language: Race: Ethnicity

Employment Status: Employed Full-Time Student Part-Time Student       Employer/School Name

Marital Status 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:

Tertiary

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:

Medical History


What is the reason for your visit?

Do you have a history of eye injuries, eye infections, eye surgeries, or eye diseases? If so, please explain.

Are you taking any medications for your eyes?
When was your last eye exam?
Who was your last eye doctor?
Which of the following best describes your use of glasses or contact lenses?
Are you planning to get new glasses?
Are you interested in contact lenses?
What type of contact lenses have you worn in the past?
How long do you typically wear your contact lenses?
How often do you typically replace your contact lenses?
What type of contact lense cleaner do you typically use?

Do you have a history of injuries, surgeries, or hospitalization? If so, please explain.


Please list any medications you're currently taking:

Please list any medication allergies:

Who is your primary care physcian?

When was your last visit?
What was the reason for this visit?
Are you currently taking any of the following over-the-counter medications?
Are you currently taking any of the following vitamins?
Are you pregnant or nursing?
Have you had a recent tetanus shot?
Have you had a recent immunization?
Do you use tobacco?
What type?
Do you use alcohol?
What type?

Please complete each section as it applies to your medical history.

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: Athritis, Joint Pains, Head or Neck Injury
SKIN: growths, rashes, acne
NEUROLOGICAL: Headaches, migraines, seizures
PSYCHIATRIC: Depression, Anxiety, Insomnia
ENDORCRINE: Thyroid, Diabetes
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux
GENERAL: Fever, weight loss, weight gain, fatigue?

Please select if you have a FAMILY history of the following.

Do you have a family history of diabetes?
Do you have a family history of heart disease?
Do you have a family history of high blood pressure?
Do you have a family history of cancer?
Do you have a family history of arthritis?
Do you have a family history of thyroid disease?
Do you have a family history of high cholesterol?
Any other family history?


Do you have a family history of glaucoma?
Do you have a family history of cataracts?
Do you have a family history of macular degeneration?
Do you have a family history of retinal detachment?
Do you have a family history of crossed / lazy-eye?


SUBMIT

After Completing all forms, please submit your data. We look forward to seeing you soon!