New Patient Form
Demographics
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Miss
Address:
City:
State/ZipCode
TX
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
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. Simonson, David
Misc/Guardian
Billing Information
Is The Billing Address the Same?
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Miss
Address
City
State
ZipCode
TX
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
Home Phone:
Work Phone:
Vision Benefits
Insurance Information
Insurance Name:
None
AETNA
ANTHEM BCBS
BCBS BLUE VIEW VISION
BENEFIT ADMINISTRATION SERVICES
CEBT/UMR
CIGNA Open Access Plus/PPO
CO MEDICARE
COLORADO ACCESS
CORIZON HEALTH
DEPARTMENT OF VETERAN AFFAIRS
Developmental Pathways
ENVISIONS
EYEMED
HUMANA
KAISER
MERITAIN HEALTH
ROCKY MOUNTAIN UFCW
SUPERIOR VISION
TRICARE
UMR
UNITED AMERICAN INSURANCE
UNITED HEALTCARE
VCP Comp Benefits/Humana
VCPN Colorado Contractors Trust
VISION SERVICE PLAN
WELD COUNTY AREA ON AGING
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:
None
AETNA
ANTHEM BCBS
BCBS BLUE VIEW VISION
BENEFIT ADMINISTRATION SERVICES
CEBT/UMR
CIGNA Open Access Plus/PPO
CO MEDICARE
COLORADO ACCESS
CORIZON HEALTH
DEPARTMENT OF VETERAN AFFAIRS
Developmental Pathways
ENVISIONS
EYEMED
HUMANA
KAISER
MERITAIN HEALTH
ROCKY MOUNTAIN UFCW
SUPERIOR VISION
TRICARE
UMR
UNITED AMERICAN INSURANCE
UNITED HEALTCARE
VCP Comp Benefits/Humana
VCPN Colorado Contractors Trust
VISION SERVICE PLAN
WELD COUNTY AREA ON AGING
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
Yes
No
Other
If Yes: Details
controlled by diet/excercise
Borderline
PreHTN 120-139/80-89
Stage1 140-159/90-99
Stage2 160+/100+
Other
If you have hypertension, what your most recent BP reading (either at home or at your physicians office)
Thyroid Problems
Yes
No
Other
If Yes: Details
Hyperthyroid
Grave's disease
Hypothyroid
Hashimoto's disease
Other
Cardiovascular / Heart problems
Yes
No
Other
If Yes: Details
A-fib
abdominal aneurism
aortic aneurism
heart attack
lymphedema
murmur
peripheral arterial disease
Raynaud's disease
stroke
Other
Cancer
Yes
No
Other
If Yes: Details
active
cured
remission
basal cell
bladder
bone
brain
breast
cervical
colon
esophageal
leukemia
liver
lung
lymphoma
melanoma
myeloma
ovarian
pancreas
prostate
squamous cell
stomach
testicular
thyroid
Other
Diabetes
Yes
No
Other
If Yes: Details
Type 1 Diabetes
Type 2 Diabetes
gestational diabetes
hypoglycemic
borderline, controlled by diet/excercise
Other
What year were you diagnosed with diabetes?
How often do you check your blood glucose?
Rarely
few times per week
1x per day
2x per day
3x per day
4x per day
5x per day
Other
What was your last Hemoglobin A1c?
unknown to pt
5
6
7
8
9
10
11
12
Other
Women: Are you currently Pregnant or Nursing?
No
Unsure
Pregnant
Nursing
Other
List any major injuries or surgeries YOU have had:
What is your approximate height:
Feet
Inches
What is your approximate weight in lbs:
REVIEW OF SYSTEMS
General
good
fatigue
fever
loss of appetite
weight gain
weight loss
Muscle weakness
Excessively tired
trouble sleeping
cough
Other
Ear Nose Throat
None
chronic cough
congestion
daytime drowsiness
dry mouth/throat
gasp while sleeping
headache
hearing problems
heavy snoring
morning headaches
runny nose
sinus problems
sleep apnea
tinnitus
toothache
Other
Cardiovascular
None
chest pain
racing heartbeat
shortness of breath
swollen feet/ankles
transient ischemic attacks (TIA)
stroke
vascular disease
hypertension / high blood pressure
Other
Respiratory
None
chronic cough
productive cough
shortness of breath
wheezing
Asthma
Emphysema
COPD
Bronchitis
Other
Genital / Urinary
None
overactive bladder
painful urination
underactive bladder
urgency in urination
urinary incontinence
excessive thirst
frequent urination
ED
Other
Gastrointestinal
None
abdominal pain
bloody stools
constipation
dark urine
diarrhea
gastric reflux (GERD)
jaundice
nausea
vomiting
Irritable Bowel Syndrome (IBS)
gastric ulcers
Other
Endocrine
None
---Hyperthyroid---
heat intolerance
sweaty
diarrhea
mood swings
palpitations
weight loss
decreased menstruation
---Hypothyroid---
cold intolerant
fatigue
depression
hair loss
heavy periods
constipation
dry skin
---Diabetes---
frequent urination
thirst
hunger
dizziness
sweating
headache
---Adrenal---
chronic hypotension
darkening of skin
---Reproductive---
menstrual changes
changes in libido
ED
Other
Muscular / Skeletal
None
decreased range of motion
joint pain
muscle cramps
stiffness
swelling
weakness
Fibromyalgia
Ankylosing spondylitis
Other
Skin
None
acne
blisters
cysts
dandruff
eczema
erythema
growths
hives
nodules
psoriasis
rash
rosacea
seborrheic / actinic keratosis
ulcerations
warts
Rosacea
skin cancer - basal cell
skin cancer - squamous cell
skin cancer - melanoma
Other
Neurologic
None
balance problems
changes in senses
dementia
memory problems
muscle weakness
numbness/tingling
personality changes
speech problems
tremors
vertigo
Multiple Sclerosis
Epilepsy
migraine headaches
other headaches
seizures
paralysis
memory loss
Other
Psychiatric
None
anxiety
bipolar
changes in eating habits
changes in sex drive
delusions
depression
excess anger
excessive worrying
frequent mood changes
hallucinations
insomnia
obsessive/compulsive
paranoia
social withdrawal
substance abuse
suicidal
violence
Other
Hemologic / Lymph
None
anemia
bleeding gums
cuts slow to clot
easy bruising
heavy periods
hx of significant blood loss
jaundice
nosebleeds
pale skin
pounding in ears
rapid hearbeat
shortness of breath
high cholesterol
anemia
leukemia
Other
Immune
None
asthma
hives
itching
mild allergy symptoms
severe allergy symptoms
redness
sneezing
swelling
seasonal allergies
Lupus
Rheumatoid arthritis
HIV / AIDS
Other STD
Other
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?
None
All year
Spring worst
Summer worst
Fall worst
Spring and summer worst
Spring and fall worst
Other
Have YOU had the flu vaccine in the past 12 months?
Yes
No
Other
Who is your primary care physician?
Dr McDermott
Dr Green
Other
When was your last medical check up with them?
Unknown
1 year
2 years
Other
Do you see any other medical specialists? If yes who?
None
Other
Do you have a preferred pharmacy?
None
Dale's Pharmacy
Safeway Fort Lupton
King Soopers Brighton
Walgreens Brighton
Walmart Brighton
Kmart Brighton
Safeway Firestone
King Soopers Firestone
Other
Do you currently have, or have you ever had any of the following:
Glaucoma
Yes
No
Other
Macular Degeneration
Yes
No
Other
Retinal problems / detachment
Yes
No
Other
Cataracts
Yes
No
Other
Lazy Eye / Amblyopia / Eye Turn
Yes
No
Other
Keratoconus / Corneal Problems
Yes
No
Other
LASIK / PRK / RK / Refractive surgery
Yes
No
Other
Blindness
No
Yes - right eye
Yes - left eye
Yes - both eyes
Other
Do you experience any of the following?
Distance Blur (with current glasses or contacts)
Yes
No
Other
Near Blur (with current glasses or contacts)
Yes
No
Other
Blur at computer (with current glasses or contacts)
Yes
No
Other
Discomfort when viewing distance
Yes
No
Other
Discomfort when viewing near
Yes
No
Other
Discomfort while using computers
Yes
No
Other
Increase in light sensitivity
Yes
No
Other
Double vision
Yes
No
Other
Flashes of light
Yes
No
Other
Floaters or Spots in vision
Yes
No
Other
Headaches associated with your vision
Yes
No
Other
Fluctuating vision
Yes
No
Other
Temporary loss of vision
Yes
No
Other
Dry eyes
Yes
No
Other
Burning or stinging eyes
Yes
No
Other
Red eyes
Yes
No
Other
Watering eyes
Yes
No
Other
Itching eyes
Yes
No
Other
Difficulty focusing between distance and near
Yes
No
Other
Haloes around lights
Yes
No
Other
Glare from lights
Yes
No
Other
List any EYE injuries or surgeries YOU have had:
Any other EYE conditions that YOU have?
List any prescription eye drops that YOU use:
None
Restasis
Pred Forte
Moxeza
Pataday
Patanol
Lumigan
Xalatan
Combigan
Tobradex
Zylet
Other
List any over the counter eye drops that YOU use:
None
Alaway
Clear Eyes
Genteal Gel
Refresh Tears
Refresh Optive
Refresh Optive Advanced
Refresh PM
Systane Tears
Systane Ultra
Systane Balance
Theratears
Visine
Zaditor
Other
When was your last eye exam?
Who was the previous eye doctor?
Dr. Simonson
Dr. Fair
Dr. Stennis
Dr. Brown
Dr. Wright
Vision Works
Walmart
Lenscrafters
Target
Other
Do you currently wear glasses?
Yes - Full time wear
Yes - part time wear
Yes - Near only use
Yes - Distance only use
No
Other
Do you currently wear contact lenses?
No
Yes - every day
Yes - some days
Yes - rarely use
Other
How many hours per day do YOU spend doing these tasks?
Desktop Computer
0
<1
1
2
3
4
5
6
7
8
9
10
11
12
Other
Laptop Computer
0
<1
1
2
3
4
5
6
7
8
9
10
11
12
Other
Tablet Computer
0
<1
1
2
3
4
5
6
7
8
9
10
11
12
Other
Smart phone / Blackberry
0
<1
1
2
3
4
5
6
7
8
9
10
11
12
Other
Reading books / documents
0
<1
1
2
3
4
5
6
7
8
9
10
11
12
Other
Driving
0
<1
1
2
3
4
5
6
7
8
9
10
11
12
Other
Any other visually demanding tasks you do?
None
Other
What hobbies / activities do you participate in?
Arts and Crafts
Astronomy
Baseball
Basketball
Boating
Computer games
Cooking
Dancing
Diving
Fishing
Football
Gardening
Golf
Hiking
Horseback Riding
Hunting
Kid's activities
Models
Needlepoint
None
Paddling
Painting
Photography
Piano
Reading
Roller Blading
Running
Sewing
Skiing
Soccer
Softball
Swimming
Tennis
Travel
Video Games
Woodworking
Other
FAMILY HISTORY
Check if your family history is unknown
Glaucoma
None
Mother
Father
Sibling
Other
Macular Degeneration
None
Mother
Father
Sibling
Other
Retinal Detachment
None
Mother
Father
Sibling
Other
Lazy Eye / Amblyopia
None
Mother
Father
Sibling
Other
Diabetes
None
Mother
Father
Sibling
Other
Other Eye Conditions / Disease (who and what condition did they have?)
None
Mother
Father
Sibling
Other
Marital Status
Never Married
Married
Divorced
Widowed
Legally Separated
Annulled
Domestic partner
Interlocutory
Polygamous
Other
Do you live alone?
Yes
No
assisted living
nursing home
Other
Do you smoke?
Never smoker
Former smoker
Current every day smoker
Current some day smoker
Unknown
Smoker - unknown current status
Light smoker (<10 cigs/day)
Heavy Smoker (>10 cigs/day)
Decline to answer
Other
Preferred Language
English
Spanish
Other
Race
White
Black or African American
American Indian or Alaskan Native
Asian
Native Hawaiian or Other Pacific Islander
Other Race
Decline to answer
Other
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Unknown
Decline to answer
Other
If you currently wear contact lenses, please list the brand, power and BC (base curve) of your contact lenses (if known):
Other
Submit Data
After Completing All Forms Submit Data on Final Tab