New Patient Form

Demographics

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

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

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 Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed Employer/School Name Primary Doctor No Doctor Assigned Dr. Claffie, Sean Dr. Hinel, Erich Dr. Yeagle, Lori Dr. Ronau, Elizabeth Dr. Schroer, Ken Dr. White, Jennipher Dr. Schneider, Lawrence Dr. Cunningham, Sierra Dr. Yeagle, Lori Dr. McFadden, Clay Misc/Guardian

Billing Information

Is The Billing Address the Same?

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

Address

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

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None New Insurance Aetna Anthem Avesis Eye Med GEHA Humana Iron Workers Southern Ohio Lions Club Lions Club Kentucky Medicare New Insurance Other Ticona United Health Care Veteran Affairs VSP Western & Southern
Insurance Plan:
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:	None New Insurance Aetna Anthem Avesis Eye Med GEHA Humana Iron Workers Southern Ohio Lions Club Lions Club Kentucky Medicare New Insurance Other Ticona United Health Care Veteran Affairs VSP Western & Southern
Insurance Plan:
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:

Vision Plan

Insurance Information

Insurance Name:	None New Insurance Aetna Anthem Avesis Eye Med GEHA Humana Iron Workers Southern Ohio Lions Club Lions Club Kentucky Medicare New Insurance Other Ticona United Health Care Veteran Affairs VSP Western & Southern
Insurance Plan:
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:

Chief Complaint

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Reason for Visit

CHIEF COMPLAINT

distance vision blurry near vision blurry vision blurry distance and near red eye pain in eye loss of vision injury to eye needs new glasses wants to be fitted for contacts itching burning stinging dry eyes Diabetic eye exam Routine EyeMed or VisionPlan exam No medical complaints Rx check Other

Secondary Complaints:

Last Eye Exam:

1 year 2 years 3 years Other

Doctor:

Doesn't Remember Abbas Blount Boyle Broussard Cass Chuckweike Conroy DeRouen Diaz Doucet EyeMart EyeMasters Fracht Harmon Hyde Johnson Lehman Lens Crafters Levacy Maynard Never Pearl Rising Singla Yu Other

Review of Ocular System

Injuries, Infections, Surgeries, Diseases	No Past Ocular Problems Itching Burning, Stinging Amblyopia Eye Injuries Eye Surgery Flashes Of Light Floaters Strabismus Cataracts Glaucoma Retinal Disorders Glaucoma suspect Macular Degeneration Vein Occlusion/Stroke Lasik Cataract Surgery Other
Eye Medications:	None Cromolyn NA 4% Visine Patanol Xalatan Travatan rewetting drops Elestat Vigamox Alphagan Refresh Theratears Genteal Pred Forte Lotemax Alrex Systane Blink Other

Family Ocular History

Glaucoma:	No Parents Sibling Grandparent Other	Cataracts:	No Parents Siblings Grandparent Other
Macular Degeneration:	No Parents Siblings Grandparent Other	Retinal Detachment:	No Parents Siblings Grandparent Other
Crossed / Lazy:	No Parents Siblings Grandparent Other

Previous Vision Correction

Primary Vision Correction:

None Glasses-Full Time Glasses-Readers Only Contacts - Soft RGPs SynergEyes Scleral Lenses Glasses & Contacts Other

Do you have backup glasses??

No Yes Other

Are you planning to get new glasses?

Yes No Other

Type of contacts worn in past:	None Disposable Conventional Colored RGP Soft Toric SynergEyes Scleral Lenses Other	Wear Time:	N/A 8 - 10 Hours All day Occ. Overnight Extended Other
Cleaner:	N/A Clear Care Boston Renu OptiFree True Moist BioTrue Revitalens OptiFree Replenish Generic Multi-purpose OptiFree Replenish Ao-Sept Clear Care Generic Multipurpose Peroxiclear Other	Disposal:	N/A 2 weeks monthly daily weekly yearly When uncomfortable Other

NOTES:

Demographics

Preferred Language:	English French German Spanish Other	Second Language	None English French German Spanish Other
Race:	Unknown Caucasian African Decent Hispanic Asian Other	Sex	Unknown Male Female Other

Review of Systems

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Review of Systems

Do you currently have any of these problems?

GENERAL: Fever, weight loss, weight gain, fatigue?	None Negative Fever Weight loss Fatigue Other
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat	None Allergies Sinus Problems Chronic Cough Dry Throat / Mouth Hard of Hearing Other
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease	None High BP Surgery Vascular Disease Other
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD	None Asthma Bronchitis Emphysema COPD Other
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence	None painful urination frequent urination impotence yellow jaundice Other
MUSCLES, BONES, JOINTS: Athritis, Joint Pains, Head or Neck Injury	None joint pain stiffness swelling cramps arthritis Other
SKIN: growths, rashes, acne	None pimples, warts growths rash Other
NEUROLOGICAL: Headaches, migraines, seizures	None numbness, paralysis headache seizures migraines Other
PSYCHIATRIC: Depression, Anxiety, Insomnia	None anxiety depression insomnia Other
ENDORCRINE: Thyroid, Diabetes	None hypothyroid hyperthoyroid Diabetes Type I - Controlled Diabetes Type I - Uncontrolled Diabetes Type II - Controlled Diabetes Type II - Uncontrolled Other
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems	None bleeding cholestrolemia anemia Other
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus	None sneezing swelling redness itching hives lupus Other
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux	None Diarrhea Constipation Ulcer Acid Reflux Other

Patient Information

Primary Care Physician

None Other

Last Visit

Few days Few weeks Few months Few years Several years Other

Pregnant Or Nursing:

No Yes Unsure Other

Recent changes to health or medications

Occupation:

Smoking	Never a smoker (cigarettes, pipes, cigars) Cigar or pipe only Former smoker Occasional smoker Smokes regularly Other	QTY	<4 per day Half pack/day (12) Pack / day >1 pack/day Other	Duration:	<1 year <5 years <10 years <20 years Other
Alcohol:	No Yes Occasionally Socially Other	QTY	1-2 drinks/week 4-6 drinks/week 6-10 drinks/week >10 drinks/week Other
Recreation Drugs	No Yes Other	Type:	Marijuana Cocaine Muscle Relaxers Heroin Other	Duration
STD:	None Gonorrhea Syphilis Hepatitis HIV Herpes Other

Medications

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Medications

Please list any medications you're currently taking:

None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Other	None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Other	None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Other
None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Other	None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Other	None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Other

Family Medical History

Hypertension	No Yes Other	Who	One or more parent Sibling Grandparents Other	Cancer	No Yes Other	Who	One or more parent Sibling Grandparents Other
High Cholesterol	No Yes Other	Who	One or more parent Sibling Grandparents Other	Autoimmune Dx	No Arthritis Other	Who	One or more parent Sibling Grandparents Other
Diabetes	No Yes Other	Who	One or more parent Sibling Grandparents Other

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