New Patient Form - Please fill out each tab


Title First Last MI Suffix Nickname
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
Misc/Guardian How did you hear about us?
Billing Information Is The Billing Address the Same?
Title First Last MI Suffix

City State ZipCode
Home Phone:
Work Phone:

Medical History

These initial questions are required to meet the Government meaningful use criteria for electronic records and will only be used for that purpose.

Preferred Language Race Ethnicity

Height - feet In Weight Have you had a flu shot?

Welcome to Our Office-Please fill out all applicable fields

Briefly describe the main reason for having an examination today:

Associated: Do you have any other symptoms related to this?

I currently wear glasses:   Full-time    Part-time  

If part-time, how often/when?   

I currently wear contacts:   Full-time    Part-time             Soft     Rigid Gas Permeable

If part-time, how often/when?        

Contact Lens Wearers:

Current Brand:         Are your lenses comfortable?  Yes    No   
How old is your current pair?        What is your replacement schedule?           What solution do you use?   

Please list all eyedrops you use (OTC and Rx):            How often used?:

Do you have a history of any of the following?                                            Are you currently experiencing any of the following?
            SET ALL TO NO                                                                                       SET ALL TO NO
                                      YES NO                                                                    YES  NO                                                   YES NO
                    Blindness                                                       Headaches                                               Eyes itch    

Eye Turn (Strabismus)                                                   Blurred Vision                                             Eyes burn       

Lazy Eye (Amblyopia)                                                   Double Vision                                              Eyes tear    

              Keratoconus                                          Eyes "hurt" or "tired"                                         Eyes feel dry    

                  Glaucoma                                             Halos around lights                            Eyes feel sandy/gritty     

                   Cataracts                                Bothered by light / sun light                                        Flashing lights    

Macular Degeneration                                                   Frequent styes                                                Floaters    

     Retinal Detachment                                           Eyes frequently red        

List any eye surgeries:                                                           Other eye disease or condition                                              Describe any eye injuries: 

How many hours a day do you use a computer?        Describe any visual symptoms from computer use:    


Physician's Name:       Last Visit Date:   

List all medications you are currently taking (including any OTC/vitamins):                    List any medications you are allergic to: 

Are you pregnant or nursing? Yes    No              If yes, what is the due/birth date?   

Do you have, or ever had, any CHRONIC problems in the following areas?SET ALL TO NO 

                            YES  NO                                               YES  NO                           YES NO
            Migraines                     High blood pressure                   Arthritis     
Multiple Sclerosis                       Allergies/Hay fever                    Stroke      

             Diabetes                                         Asthma                   Anemia      

Thyroid problems                                  Emphysema                    Cancer         




Family history is unknown/adopted

Any history of the following in any family members (parents, grandparents, siblings, children)? SET ALL TO NO 

                                            YES No    RELATIONSHIP TO PATIENT                                             YES NO    RELATIONSHIP TO PATIENT     
                        Poor Vision                                                                 Cancer                
                             Blindness                                                               Diabetes                    

          Eye turn (Strabismus)                                                  High Blood Pressure        
        Lazy Eye (Amblyopia)                                                                   Stroke           

                          Glaucoma                                                      Thyroid Disease                
                           Cataracts                                                    Inherited Disease              
         Macular Degeneration                                                        what disease?    

Retinal Detachment/Disease           


SOCIAL HISTORY (confidential)

How often do you smoke/use tobacco products?  
How often do you consume alcohol?             

Do you have? HIV    Hepatitis   STDs


Who referred you to our office?     

If not referred, how did you hear about Pearson Eyecare Group?   

Submit Data

After Completing All Forms Submit Data on Final Tab