New Patient Form

Demographics

Title First Last MI Suffix Nickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Referred By:
Cell Phone: Preferred Contact Method:
SSN Email
DOB Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Parent/Guardian
Billing Information Is The Billing Address the Same?
Title First Last MI Suffix
Address

City State ZipCode
Home Phone:
Work Phone:

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:
Birthdate:
SSN:
Employer/School:

Vision 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:
Birthdate:
SSN:
Employer/School:

Medical History


Please fill out this entire form to the best of your knowledge. Thank you.

ASSESSMENT
Race Ethnicity Preferred Language
Alcohol Smoking Status
Height: Ft. In. Weight: Lbs. PG/Nursing

Primary Care Provider      List any hobbies you enjoy:

List all prescribed medications and dosages: List any vitamins/supplements taken:
No Meds Taken List any drug and/or seasonal allergies
No known drug allergies

Last Eye Exam
Last Physical Exam Primary Care Provider


Review of Systems
Do you have symptoms of: (Please list all that apply)
General Health (good, cold, fever, fatigue, loss of apetite, weight gain, weight loss):

Ear/Nose/Throat (none, chronic cough, congestion, headache, hearing problems, runny nose, sinus problems, sleep apnea):

Cardiovascular Disease (none, arrhythmia, chest pain, heart disease, high blood pressure, high cholesterol, shortness of breath, stroke, swollen feet/ankles):

Pulminary (none, asthma, chronic cough, COPD, cyanosis, emphysema, shortness of breath, wheezing):

Genitourinary/Urilogical (none, overactive bladder, painful urniation, prostate, underactive bladder, urinary incontinence):

Gastrointestinal (none, acid reflux(GERD), bronzing of skin, constipation, dark urine, diarrhea, jaundice, nausea, vomiting):

Endocrine (none, cold intolerance, diabetes, excess thirst, frequent urination, heat intolerance, hyperthyroid, hypothyroid):

If you have diabetes, please indicate: Year diagnosed: A1c

Musculoskeletal (none, arthritis, fibromyalgia, joint pain, muscle cramps, stiffness, swelling, weakness):

Skin (none, acne, blisters, cysts, eczema, psoriasis, rash, rosacea, scales):

Neurological (none, cerebral palsy, dementia, epilepsy, memory problems, multiple sclerosis, numbness, tingling, tremors, vertigo):

Psychiatric (none, ADHD, anxiety, depression, hallucinations, insomnia, paranoia, social withdrawal, substance abuse):

Hematological/Lymph Node (none, bleeding, bleeding gums, easy bruising, jaundice, nosebleeds, pale skin, pounding in ears):

Immune (none, AIDS, HIV+, lupus, mild allergy symptoms, redness of skin, severe allergy symptoms, sneezing):


Family History
Has any member of your family been diagnosed with the following:
Pt Mt Ft Sib No Please explain
Diabetes
Hypertension
Thyroid
Cardiovascular Disease
Cancer

Ocular History
Have you or any member of your family been diagnosed with the following:
Pt Mt Ft Sib No Please explain
Glaucoma
Age-related Macular Degeneration
Retinal Detachment
Cataract
Amblyopia/Crossed-eye


List any eye surgeries/eye injuries:
List any other medical history:


Submit Data

After Completing All Forms Submit Data on Final Tab