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 Employment Status
Marital Status Employer/School Name
Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Medical History



Personal / Social History

Referred By:
TYPE OF AD?
Family Patients:
Hobbies:
Interested In Contact Lenses?
Ever Worn Contact Lenses?
Type of CLs worn in past:
Back up specs for cls?
Primary Vision Correction:
Sunspecs?
Computer glasses?
Problems with glare?
Interested in Laser Vision Correction?
Eye Hx: Sting, Burn, Itch, Surg.,Injury,Cats, Ambly.,Floaters, GL, Strab., Retinal
Eye Meds:
Last Eye Doctor:
Primary Care Physician:
Systemic Meds:
Med Hx: HAs,Arthritis,Asthma,Diabetes,HBP,Heart,Infl. Bowel Dz,Seizures,Thyroid,Smoke,Pregnant,Nursing,HIV+
Family Med History:
Family Eye History:
Medication and Seasonal Allergies:
NOTES/SOCIAL HISTORY


Review Of Systems

General:
Ears, Nose, Throat:
Cardiovascular:
Respiratory:
Genital, Kidney, Bladder:
Muscles, Bones, Joints:
Skin:
Neurological:
Psychiatric:
Endocrine:
Blood/Lymph:
Allergic/Immunologic

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