New Patient Form

Demographics

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

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

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


Please answer every question. Select No or None rather than leave any question blank.
Provide more details on Yes answers. Select Other to write in your own information.


Do YOU have any of the following?
High Blood Pressure / Hypertension If Yes: Details
If you have hypertension, what your most recent BP reading (either at home or at your physicians office)

Thyroid Problems If Yes: Details
Cardiovascular / Heart problems If Yes: Details
Cancer If Yes: Details
Diabetes If Yes: Details
What year were you diagnosed with diabetes?
How often do you check your blood glucose?
What was your last Hemoglobin A1c?
Women: Are you currently Pregnant or Nursing?


List any major injuries or surgeries YOU have had:


What is your approximate height:
FeetInches

What is your approximate weight in lbs:

REVIEW OF SYSTEMS
General
Ear Nose Throat
Cardiovascular
Respiratory
Genital / Urinary
Gastrointestinal
Endocrine
Muscular / Skeletal
Skin
Neurologic
Psychiatric
Hemologic / Lymph
Immune

Do you have any other Medical concerns or problems?

List all medications that YOU take:

List all Vitamins / Supplements that YOU take

List any signficant Allergies that YOU have (medication, food, etc.):

Do you have seasonal allergies?
Have YOU had the flu vaccine in the past 12 months?
Who is your primary care physician?
When was your last medical check up with them?
Do you see any other medical specialists? If yes who?
Do you have a preferred pharmacy?


Do you currently have, or have you ever had any of the following:
Glaucoma
Macular Degeneration
Retinal problems / detachment
Cataracts
Lazy Eye / Amblyopia / Eye Turn
Keratoconus / Corneal Problems
LASIK / PRK / RK / Refractive surgery
Blindness







Do you experience any of the following?
Distance Blur (with current glasses or contacts)
Near Blur (with current glasses or contacts)
Blur at computer (with current glasses or contacts)
Discomfort when viewing distance
Discomfort when viewing near
Discomfort while using computers
Increase in light sensitivity
Double vision
Flashes of light
Floaters or Spots in vision
Headaches associated with your vision
Fluctuating vision
Temporary loss of vision
Dry eyes
Burning or stinging eyes
Red eyes
Watering eyes
Itching eyes
Difficulty focusing between distance and near
Haloes around lights
Glare from lights
















List any EYE injuries or surgeries YOU have had:

Any other EYE conditions that YOU have?


List any prescription eye drops that YOU use:
List any over the counter eye drops that YOU use:

When was your last eye exam? Who was the previous eye doctor?
Do you currently wear glasses? Do you currently wear contact lenses?


How many hours per day do YOU spend doing these tasks?
Desktop Computer Laptop Computer Tablet Computer
Smart phone / Blackberry Reading books / documents Driving
Any other visually demanding tasks you do?

What hobbies / activities do you participate in?

FAMILY HISTORY

Check if your family history is unknown

Glaucoma Macular Degeneration Retinal Detachment
Lazy Eye / Amblyopia Diabetes
Other Eye Conditions / Disease (who and what condition did they have?)

Marital Status Do you live alone? Do you smoke?
Preferred Language Race Ethnicity

If you currently wear contact lenses, please list the brand, power and BC (base curve) of your contact lenses (if known):

Submit Data

After Completing All Forms Submit Data on Final Tab