New Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
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:

Vision

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

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


Referred By:    Referring Doctor:   Preferred Language: 

Occupation:    Computer Use:    Gender: 

Race:    Ethnicity: 

Hobbies:


Height Feet:   Inches:   Weight: 

PATIENT AND MEDICAL HISTORY:

Last Eye Exam:    Last Eye Doctor: 

OCULAR HISTORY
                                              SELF   RELATIVE  SELF
Cataracts                                     Dryness or pain in eyes
Glaucoma                                     Blurred Vision
Macular Degeneration                                     Double Vision
Retinal Disease                                     Eye Infection
Eye Disease                                     Eye Injury
Eye Surgery                                     Floaters  New/worse? 
                                               Flashes   New/worse? 
Other ocular conditions/Notes:


Eye Meds: 

Last Medical Exam:    Primary Care Physician:    PCP Phone Number: 

MEDICAL HISTORY
                                            SELF   RELATIVE             SELF  RELATIVE    SELF
Diabetes                             Asthma                                Head Injury
High Blood Pressure                             Thyroid                                Nursing
Elevated Cholesterol                             Cancer                                 Pregnant
Lung Disease                             Migraines                
Heart Disease                             Headaches              


Any other medical conditions/Notes:


Systemic Meds:


Allergies (Medications and Seasonal): 

PERSONAL AND SOCIAL HISTORY:

Smoking Status   Amount:    Alcohol Status:    Amount: 

Primary Vision Correction:
  Age of current glasses:    Sunspecs?    Interested in Corrective Eye Surgery? 

H/o Contact Lenses Wear?    Interested In Contact Lenses?    If no, why not? 

Brand of CLs worn in the past:   Replacement Frequency:    Solution: 

Drops?    EW?    How many nights/week?    Back up specs for Contact Lenses? 

NOTES

Review of Systems


REVIEW OF SYSTEMS

DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?

GENERAL:  Fatigue Weight gain Weight loss Chronic fever None

CARDIOVASCULAR:  Heart surgery Irregular Heartbeat Chest Pain None

EAR, NOSE, THROAT: Hearing loss  Sore throat  Sinus   None

RESPIRATORY:  Asthma  Shortness of Breath  Bronchitis  Emphysema  COPD  None

GASTROINTESTINAL: Heartburn  Vomiting  Abdominal pain  None

GENITOURINARY:  Kidney  Bladder/Urinary  Genital  None

MUSCULOSKELETAL: Arthritis  Muscle Pain  Joint Pain  Head or neck injury  None

SKIN: Growths  Rashes   Acne  Excessive Dryness  None

NEUROLOGICAL: Headaches  Migraines  Seizures  Numbness  None

PSYCHIATRIC: Depression  Anxiety  Insomnia  None

ENDOCRINE: Diabetes   Thyroid  Problems with other glands  None

BLOOD/LYMPH:  Anemia   Cholesterol  Bleeding problems   None

ALLERGIC / IMMUNOLOGIC:  Lupus  Seasonal Allergies  Rheumatoid  AIDS  Allergy shots  None

NOTES:

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