New Patient Form

Demographics

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

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
Email
Birthday
Sex	Male Female
Marital Status	Single Married Separated Divorced Widowed Unknown
Primary Doctor	No Doctor Assigned Dr. Kenkel, Timothy Dr. Cleary, Julie Dr. Burcham, Marc Dr. PLEIMAN, MICHELLE Dr. HECHT, STEVE

Primary

Insurance Information

Insurance Name:	None Aetna Anthem Caresource Eyemed Humana HMO Humana PPO Humana Vision Medicare Superior Vision United Health Care United Medical Resource VSP vision service plan
Insurance ID:
Insurance Policy Group:

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Phone Number:
Birthday:
Last 4 of SSN:

Ocular History

Last Eye Exam:

Never 1 year 2 years 3 years 4 years 5 years Unknown Greater than 5 years

Doctor:

or Place:

Apex Cincinnati Eye Institute Eyemart Midwest TriState Centers for Sight Walmart Wing Eyecare Unknown Other

Ocular History: List of Surgeries, Amblyopia/Lazy Eye, Stabismus/Eye Turn, Significant Trauma, Cataracts, Glaucoma, Macular Degeneration, History of Wearing Contacts

Do you use any of the following eye medications?

None Other Visine Patanol Alphagan Timolol Xalatan Travatan rewetting drops Elestat Vigamox Refresh Theratears Genteal Pred Forte Lotemax Alrex Systane Blink

Primary Vision Correction:

None Glasses-Full Time Glasses-Readers Only Contacts - Soft RGPs Glasses-Distance Only

If you primarily wear contact lenses, do you have back up glasses?

Yes No

Are you planning to get new glasses?

Yes No

FAMILY OCULAR HISTORY:

Glaucoma:

No Mother Father Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather More than 1 family member

Cataracts:

No Mother Father Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather More than 1 family member

Macular Degeneration:

No Mother Father Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather More than 1 family member

Retinal Detach:

No Mother Father Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather More than 1 family member

Crossed / Lazy:

No Mother Father Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather More than 1 family member

CONTACT LENS INFORMATION:

Check this box if you want a Contact Lens Evaluation at your Exam

What is your current brand or type of contact lenses?

Unknown New Wearer RGP Acuvue 2 Acuvue Advance Acuvue Oasys Air Optix Avaira Biofinity Proclear Purevision Purevision 2 Acuvue 1 day Moist Acuvue Trueye Biotrue Dailies AQP Dailies Total One Proclear Dailies Soflens Dailies

Other:

Distance Only Monovision Multifocal

How would you rate the comfort?

Good Fair Poor Dryness at end of day

How often do you sleep in your contact lenses?

Never Rarely 6 nights a week 5 nights a week 4 nights a week 3 nights a week 2 nights a week 1 night a week Every night 30 nights continuously

How often do you throw away your contacts and put in a new pair?

2 weeks monthly daily weekly yearly

Medical History

Occupation:

Race: Required to ask per the Affordable Care Act

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Declining to answer or unknown

Preferred Language: Required to ask per the Affordable Care Act

English French German Spanish Other

Ethnicity: Required to ask per the Affordable Care Act

Non Hispanic or Latino Hispanic or Latino Declining to answer or unknown

Who is your Primary Care Physcian:

Last Visit to Primary Care Doctor:

1 week 1 month 3 months 6 months 1 year 2 years

Problems List: Examples include Diabetes, Hypertension, High Cholesterol, Multiple Sclerosis, Sarcoidosis, Lupus, Osteo Arthritis, Rheumatoid Arthritis, Cancer, Hypothyroid, Hyperthyroid, Cancer, COPD, Asthma, Sickle Cell

Medications: Please list all current medications and their dosages

No current medications

OTC:

None Asprin Acetomenophin Ibuprofen Allegra Claritin Zyrtec Other

Vitamins:

None A E C Zinc Xanten Multivitamin Lutein AREDS Other

Allergies: Please list all current known allergies, and your reaction to them

No Known Allergies

Pregnant Or Nursing:

No Unsure Pregnant Nursing

Any Complications from Pregnancy:

None Preclampsia Gestational Diabetes

Significant Injuries, Surgeries, Hospitalization

Smoking Status: Never Smoker Current every day smoker Current some day smoker Former smoker Smoker, currernt status unknown Unknown if ever smoked

How Long have or did you smoke for:

FAMILY MEDICAL HISTORY:

Examples: Diabetes, Heart Disease, Cancer, Kidney, Thyroid, Other:

None Adopted Diabetes Cancer Cardiovascular Disease Kidney Disease Thyroid

Family Medical History

Family Medical Histor

Family Medical History

Family Medical History

Family Medical History

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