New Patient Form

Demographics

Title First Last MI Suffix Nickname

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 Mary E Baker, O.D.	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix

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:

Primary

Insurance Information

Insurance Name:	None AARP Administrative Concepts Inc Administrators West Aetna US Healthcare AmeriBen Care Credit CareFirst Cigna EBMS FIRST CHOICE First Choice Health Plan Great West Group Health Options Health Comp HMA HSI Direct/Boeing Australia Humana- in network Kaiser Permanente KPS Health Plans Lifewise Health Plan of Washington Locals 302/612 Health trust Med Advantage Medical Eye Services Medicare Mega Life & Health Insurance Mutual of Omaha-F New Insurance Northstar Northwest Benefit Network Northwest Laborers Pacific Heritage Administraters PacifiCare Health Plan PCLI PECCA Premera Blue Cross Principal Life Insurance Private Providence Health Plan PSEW Health Trust Rainier Collections RBMS Regence Blue Cross Blue Shield Saint Mary's Preferred Health Insurance Saint Marys HealthFirst HMO State Farm Sterling Option I TRI CARE Trusteed Plans Services Corp Uniform Medical United Healthcare United Teacher Associates Insurance Co USAA Vision Service Plan Zenith Administrators Inc.
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:	None AARP Administrative Concepts Inc Administrators West Aetna US Healthcare AmeriBen Care Credit CareFirst Cigna EBMS FIRST CHOICE First Choice Health Plan Great West Group Health Options Health Comp HMA HSI Direct/Boeing Australia Humana- in network Kaiser Permanente KPS Health Plans Lifewise Health Plan of Washington Locals 302/612 Health trust Med Advantage Medical Eye Services Medicare Mega Life & Health Insurance Mutual of Omaha-F New Insurance Northstar Northwest Benefit Network Northwest Laborers Pacific Heritage Administraters PacifiCare Health Plan PCLI PECCA Premera Blue Cross Principal Life Insurance Private Providence Health Plan PSEW Health Trust Rainier Collections RBMS Regence Blue Cross Blue Shield Saint Mary's Preferred Health Insurance Saint Marys HealthFirst HMO State Farm Sterling Option I TRI CARE Trusteed Plans Services Corp Uniform Medical United Healthcare United Teacher Associates Insurance Co USAA Vision Service Plan Zenith Administrators Inc.
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:	None AARP Administrative Concepts Inc Administrators West Aetna US Healthcare AmeriBen Care Credit CareFirst Cigna EBMS FIRST CHOICE First Choice Health Plan Great West Group Health Options Health Comp HMA HSI Direct/Boeing Australia Humana- in network Kaiser Permanente KPS Health Plans Lifewise Health Plan of Washington Locals 302/612 Health trust Med Advantage Medical Eye Services Medicare Mega Life & Health Insurance Mutual of Omaha-F New Insurance Northstar Northwest Benefit Network Northwest Laborers Pacific Heritage Administraters PacifiCare Health Plan PCLI PECCA Premera Blue Cross Principal Life Insurance Private Providence Health Plan PSEW Health Trust Rainier Collections RBMS Regence Blue Cross Blue Shield Saint Mary's Preferred Health Insurance Saint Marys HealthFirst HMO State Farm Sterling Option I TRI CARE Trusteed Plans Services Corp Uniform Medical United Healthcare United Teacher Associates Insurance Co USAA Vision Service Plan Zenith Administrators Inc.
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

Occupation

Student Retired Homemaker Engineer Other

Employer

Race

White Black Mixed Asian Caucasion Latino Other

Ethnicity

Non-Hispanic Hispanic Other

Language

English Spanish French Declined to answer Other

Computer / Day

Sports and Hobbies

Baseball Basketball Computer Football Gardening Golf Hunting Reading Sewing Shooting Soccer Swimming Other

Cigarettes or Tobacco

No 1-5 6-10 1 pack 2 packs 3 or more packs Other

Glaucoma

No Yes Other

Cataracts

No Yes Other

Macular Degeneration

No Yes Other

Other

No Yes Other

Glaucoma

No Siblings Mother Father Aunt Grandparent Uncle Other

Macular Degeneration

No Siblings Mother Father Aunt Grandparent Uncle Other

Diabetes

No Siblings Mother Father Aunt Grandparent Uncle Yes Other

Other

No Cataracts Siblings Mother Father Aunt Grandparent Uncle Other

Last Eye Exam

1 year 2 years 3 years 5 Years 10 Years Never Other

Sudden Loss of Vision

No Migrainous TIA Yes Other

Double Vision

No Blur Horizontal Vertical Constant Intermittent Rarely Often Yes Other

Flashes

No Migranous Bright Rarely Resolved Peripherally Often Yes Other

Floaters

No Mild somewhat bothersome Very bothersome Longstanding Recent Stable Normal, Typical Yes Other

Burning or Gritty or Dry

No Burn-Mild Burn-Moderate Burn-Severe Grit-Mild Grit-Moderate Grit-Severe Dry-Mild Dry-Moderate Dry-Severe Mild Moderate Severe Yes constant rarely occasionally intermittent Other

Itchy Eyes

No Seasonal Animals Rubbing Mild Moderate Severe Relief w/Rx Oral Relief w/OTC Oral Relief w/Rx Drops Relief w/OTC Drops Occasionally Yes Other

Tearing

No Rarely Occasionally Often Constant Mild Somewhat bothersome Very bothersome Yes Other

Redness

No Resolved Mild Moderate Severe Yes Other

Pain or Soreness

No Resolved Mild-Current Moderate-Current Severe-Current Occasionally Rarely Yes Other

Injury, Surgery

No Cataracts OD Cataracts OS Cataracts OU Other

OTHER

Eye Meds

Vigamox Zymaxid Besivance Moxeza Zymar Tobramycin Polytrim Pred Forte Tobradex Lotemax Zylet Alrex FML Pataday Patanol Bepreve Zaditor Simbrenza Combigan Xalatan Travatan Lumigan Cosopt Alphagan Timolol Other

Cataracts

No Yes Other

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