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:

Primary

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:

Secondary

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:

Tertiary

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

Preferred language Race Ethnicity Height ft in Weight lbs

Date of last evaluation:
How did you learn about our office?
Are you Interested in Contact Lenses?
Yes No
Have you ever worn contact lenses?
Yes No
Contact Lens Wearers:
Are your lenses comfortable? Yes No
Current Brand:
What solution do you use?
What is your replacement schedule?
How old is your current pair?

SOCIAL HISTORY
This information is required by insurance carriers and is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer. If so, check here:
Smoking Status
Do you drink alcohol?
Yes No If yes, type/amount/how often:
Do you use illegal drugs?
Yes No If yes, type/amount/how often:
Are you currently or have you ever been infected with:
Tuberculosis
Yes No
Hepatitis
Yes No
HIV
Yes No
Syphilis
Yes No
Chlamydia
Yes No

Eyes
Do you experience any of the following?
Blurred Vision
Yes No
Burning
Yes No
Eyes feel dry
Yes No
Double Vision
Yes No
Eyes tear
Yes No
Eyes "hurt" or "tired"
Yes No
Flashes
Yes No
Floaters
Yes No
Foreign body sensation
Yes No
Eyes itch
Yes No
Bothered by light / sun light
Yes No
Halos around lights
Yes No
Redness
Yes No
Eyes feel sandy/gritty
Yes No
Mucous discharge
Yes No
Do you have a history of any of the following?
Blindness
Yes No
Eye Turn (Strabismus)
Yes No
Lazy Eye (Amblyopia)
Yes No
Patching
Yes No
Glaucoma
Yes No
Cataracts
Yes No
Macular Degeneration
Yes No
Retinal Detachment
Yes No
Eye Surgery
Yes No
Eye Injury
Yes No

MEDICAL HISTORY / REVIEW OF SYSTEMS:
Primary Care Physician: Last visit BP
Do you have any allergies to medications? Yes No If yes, please list:
Are you pregnant or nursing? Yes No N/A
Do you currently, or have you ever had, any problems in the following areas? SET ALL TO NO
1- CONSTITUTIONAL:
Fever
Yes No
Weight Loss/ Gain
Yes No
Other
2- INTEGUMENTARY (SKIN):
Herpes Zoster (Shingles)
Yes No
Eczema
Yes No
Rosacea
Yes No
Other
3- NEUROLOGICAL:
Migraines
Yes No
Seizures
Yes No
Multiple Sclerosis
Yes No
Other
4- ENDOCRINE:
Thyroid problems
Yes No
Diabetes
Yes No
Other
5- ALLERGIC/ IMUNOLOGIC:
Drug Allergy
Yes No
Enviromental Allergy
Yes No
Lupus
Yes No
Other
6- RESPIRATORY:
Asthma
Yes No
Bronchitis
Yes No
Emphysema
Yes No
Other
7- EAR/ NOSE/ THROAT:
Allergies/Hay fever
Yes No
Chronic Cough
Yes No
Sinus Congestion
Yes No
Other
8- CARDIOVASCULAR:
Heart Disease
Yes No
High blood pressure
Yes No
Stroke
Yes No
Vascular Disease
Yes No
Other
9- GASTROINTESTINAL:
Crohn's
Yes No
Colitis
Yes No
Ulcer
Yes No
Other
10-GENITOURINARY:
Genital/ Kidney/ Bladder
Yes No
Other
11- MUSCULOSKELETAL:
Arthritis
Yes No
Fibromyalgia
Yes No
Muscular Dystrophy
Yes No
Other
12- HEMATOLOGIC/ LYMPHATIC:
Anemia
Yes No
Leukemia
Yes No
Bleeding Problems
Yes No
Other
13- PSYCHIATRIC:
Depression
Yes No
Panic Disorder
Yes No
Schizophrenia
Yes No
Other
List of your current medication:

FAMILY HISTORY Family history is unknown/adopted
SET ALL TO NO
Lazy Eye (Amblyopia)
Yes No Relationship To Patient
Blindness
Yes No Relationship To Patient
Cataracts
Yes No Relationship To Patient
Glaucoma
Yes No Relationship To Patient
Retinal Detachment/Disease
Yes No Relationship To Patient
Macular Degeneration
Yes No Relationship To Patient
High Blood Pressure
Yes No Relationship To Patient
Diabetes
Yes No Relationship To Patient

Submit Data

After Completing All Forms Submit Data on Final Tab