Combs Family EyeCare New Patient Form

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Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr.

Address:
City:		State/ZipCode	OH 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 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	Unknown Single Married Separated Divorced Widowed Child	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Combs, Eric Dr. Combs, Alicia	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr.

Address

City	State	ZipCode
	OH 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 OK OR PA RI SC SD TN TX UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Medical History

This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.
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Last Exam Date:
Name of Previous Eye Doctor and/or Location:
Contact Lens Wearers: Are you happy with your current contacts?
YesNo
If yes:
Current Brand:
Solution Used:
What is your replacement schedule? Daily Weekly Every 2 weeks Monthly Quarterly Yearly
How old is your current pair?
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Review of Symptoms: Do you currently have any of these problems?


General:
Negative Recent Weight Loss Recent Weight Gain Current Fever

Ear / Nose / Throat:
Negative Hearing Loss Dry Throat / Mouth Chronic Cough Sinus Problems

Cardiovascular:
Negative Hypertension Vascular Disease Heart Surgery

Respiratory:
Negative Asthma Emphysema Bronchitis COPD

Genital / Kidney / Bladder:
Negative Kidney Stones Impotence Frequent Urination Painful Urination

Muscles / Bones / Joints:
Negative Arthritis Cramps Swelling Stiffness Joint Pain

Skin:
Negative Herpes Zoster (Shingles) Acne Rosacea Growths Rash

Neurological:
Negative Migraines Headache Multiple Sclerosis Numbness / Paralysis

Psychiatric:
Negative Insomnia Anxiety Depression

Endocrine:
Negative Hypothyroid Hyperthyroid
Diabetes if yes: What Type? Type I Type II Year Diagnosed? Fasting Blood Sugar? A1C?

Blood / Lymph:
Negative Cholesterol Leukemia Bleeding Disorder Anemia

Allergic / Immunologic:
Negative Seasonal Allergies Lupus Rheumatoid Arthritis

Gastrointestinal:
Negative Acid Reflux Celiac Disease Ulcer Constipation Diarrhea

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SOCIAL HISTORY:

Race: White Hispanic or Latino Black or African American Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander

Preferred Language: English Spanish French German Chinese

Occupation:

Hobbies:

Smoking Status: never smoked former smoker current every day smoker current some day smoker smoker, current status unkown unkown if ever smoked How Long: Type: NA Cigarettes cigars Chewing Tobacco Pipe

Alcohol Use: No Yes Socially Type: N/A Beer Wine Liquor Amt/week:

Illegal Drug Use: No Yes Type: NA How Long: NA

Exposure to STD: negative Hepatitis TB Gonorrhea Syphilis Herpes HIV Chlamydia


List of Current Medications
No current meds
Vitamins:

Personal Ocular History: Cataracts Glaucoma Macular Degeration Lazy Eye Retinal Hole or Tear Retinal Detachment Cataracts Glaucoma Macular Degeration Lazy Eye Retinal Hole or Tear Retinal Detachment Cataracts Glaucoma Macular Degeration Lazy Eye Retinal Hole or Tear Retinal Detachment Cataracts Glaucoma Macular Degeration Lazy Eye Retinal Hole or Tear Retinal Detachment
Other Ocular History Not Listed:

Injuries, Surgeries, Hospitalization:
Pregnant Or Nursing?:

Other Pertinent Personal Medical Notes:

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

Drug Allergies:
No Known Drug Allergies


FAMILY MEDICAL HISTORY

Hypertension: None Sibling Grandparent Father Mother

Heart Disease: None Sibling Grandparent Father Mother

Diabetes: None Sibling Grandparent Father Mother

Cancer: None Sibling Grandparent Father Mother

Kidney Disease: None Sibling Grandparent Father Mother

Thyroid Disease: None Sibling Grandparent Father Mother



FAMILY OCULAR HISTORY

Cataracts: None Sibling Grandparent Father Mother

Glaucoma: None Sibling Grandparent Father Mother

Macular Degneration: None Sibling Grandparent Father Mother

Retinal Detachment: None Sibling Grandparent Father Mother

Lazy Eye: None Sibling Grandparent Father Mother