New Patient Form

Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev.

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 Legally Separated Married Never Married Widowed Employer/School Name Primary Doctor Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev.

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 ADVANTRA FREEDOM ADVENTIST RISK MANAGEMENT AETNA AETNA LIFE INSURANCE AETNA MEDICARE AFLAC AGC TRUST OF MONTANA AHCCCS AMERIBEN/IEC GROUP AMERICAN BENEFIT PLAN ADMIN. American Continental AMERICAN FAMILY AMERICAN REPUBLIC AMERICAN RETIREMENT APWU ARIZONA PIPE TRADES HEALTH AND WELFARE ASPEN EDUCATION GROUP ASSURANT HEALTH AVESIS AVMA AZ HEALTH CARE COST CONTAINMENT BANKERS LIFE Banner Health BANNER HEALTH BASHAS BENEFIT TRUST BLUE CROSS BLUE SHIELD BLUE CROSS BLUE SHIELD OF MICHIGAN BLUE MEDICARE ADVANTAGE CAREMARK CHAMPVA CIGNA COLONIAL PENN COLUMBIAN MUTUAL COMMONWEALTH OF MASS. COPPER CANYON ACADEMY CSI DAVIS VISION DESERET SECURE PLUS DESERT CANYON EQUITABLE AND YOU ESSENTIAL STAFFCARE EVERANCE FIRST CHOICE HEALTH FIRST HEALTH FISERV HEALTH FOREIGN SERVICE BENEFIT PLAN GEHA GERBER LIFE INSURANCE GILSBAR GOLDEN RULE GPM LIFE GREAT WEST HEALTH NET HEALTHCARE GROUP OF ARIZONA HMA HOP ADMINISTRATION UNIT HUMANA HUMANA MILITARY LIFEWISE LIONS CLUB MAIL HANDLERS BENEFIT PLAN MBA OF MARYLAND INC. MEDI-SHARE MEDICARE MEDICO MEDIPLUS MERITAIN HEALTH MOUNTAIN STATES MOUNTAIN STATES ADMINISTRATIVE MPI HEALTH PLAN MSGA MUTUAL OF OMAHA NACOG/ AREA AGENCY ON AGING NATIONAL AUTOMATIC SPRINKLER INDUSTRY NATIONAL AUTOMATIC SPRINKLER WELFARE FUND NAVAHCS NAVAJO NATION EMPLOYEE BENEFIT PLAN NONE Northwest Administrators NORTHWEST ADMINISTRATORS ODS operating engineers bc/bs OPERATING ENGINEERS HEALTH AND WELFARE PACIFIC CARE PACIFIC CARE (ARIZONA RETIREMENT) PALMETTO GBA Ph PHOENIX HEALTH PLANS PHYSICIANS CARE PHYSICIANS MUTUAL PREMERA PRESBYTERIAN HEALTH PLAN PRINCIPAL PRIVATE PAY PYRAMID RESERVE NATIONAL INS CO ROYAL NEIGHBORS OF AMERICA SECURE HORIZONS SECURITY LIFE SOUTHWEST ADMINISTRATORS SOUTHWEST SERVICE ADMINISTRATORS SPECTERA STANDARD LIFE AND ACCIDENT STARMARK State farm SUMMIT TALL TREE ADMINISTRATORS THE MEGA LIFE AND HEALTH INSURANCE CO. THRIVENT FINANCIAL TRI CARE UMR UMWA HEALTH AND RETIREMENT UNITED AMERICAN UNITED COMMERCIAL TRAVELERS OF AMERICA UNITED FOOD AND COMMERCIAL UNITED HEALTH CARE UNITED HEALTH CARE COMMUNITY PLAN UNITED HEALTH CARE IPA UNITED HEALTH COMPANY UNITED HEALTHCARE ARIZONA RETIREMENT UNITED HEALTHCARE DUAL COMPLETE UNITED TEACHERS ASSOCIATES UNIVERSAL HEALTH CARE VISION CARE DIRECT VISION SERVICE PLAN WAKELY AND ASSOCIATES WELL CARE WOODMEN OF THE WORLD YAVAPAI APACHE TRIBE YAVAPAI TRUST
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 ADVANTRA FREEDOM ADVENTIST RISK MANAGEMENT AETNA AETNA LIFE INSURANCE AETNA MEDICARE AFLAC AGC TRUST OF MONTANA AHCCCS AMERIBEN/IEC GROUP AMERICAN BENEFIT PLAN ADMIN. American Continental AMERICAN FAMILY AMERICAN REPUBLIC AMERICAN RETIREMENT APWU ARIZONA PIPE TRADES HEALTH AND WELFARE ASPEN EDUCATION GROUP ASSURANT HEALTH AVESIS AVMA AZ HEALTH CARE COST CONTAINMENT BANKERS LIFE Banner Health BANNER HEALTH BASHAS BENEFIT TRUST BLUE CROSS BLUE SHIELD BLUE CROSS BLUE SHIELD OF MICHIGAN BLUE MEDICARE ADVANTAGE CAREMARK CHAMPVA CIGNA COLONIAL PENN COLUMBIAN MUTUAL COMMONWEALTH OF MASS. COPPER CANYON ACADEMY CSI DAVIS VISION DESERET SECURE PLUS DESERT CANYON EQUITABLE AND YOU ESSENTIAL STAFFCARE EVERANCE FIRST CHOICE HEALTH FIRST HEALTH FISERV HEALTH FOREIGN SERVICE BENEFIT PLAN GEHA GERBER LIFE INSURANCE GILSBAR GOLDEN RULE GPM LIFE GREAT WEST HEALTH NET HEALTHCARE GROUP OF ARIZONA HMA HOP ADMINISTRATION UNIT HUMANA HUMANA MILITARY LIFEWISE LIONS CLUB MAIL HANDLERS BENEFIT PLAN MBA OF MARYLAND INC. MEDI-SHARE MEDICARE MEDICO MEDIPLUS MERITAIN HEALTH MOUNTAIN STATES MOUNTAIN STATES ADMINISTRATIVE MPI HEALTH PLAN MSGA MUTUAL OF OMAHA NACOG/ AREA AGENCY ON AGING NATIONAL AUTOMATIC SPRINKLER INDUSTRY NATIONAL AUTOMATIC SPRINKLER WELFARE FUND NAVAHCS NAVAJO NATION EMPLOYEE BENEFIT PLAN NONE Northwest Administrators NORTHWEST ADMINISTRATORS ODS operating engineers bc/bs OPERATING ENGINEERS HEALTH AND WELFARE PACIFIC CARE PACIFIC CARE (ARIZONA RETIREMENT) PALMETTO GBA Ph PHOENIX HEALTH PLANS PHYSICIANS CARE PHYSICIANS MUTUAL PREMERA PRESBYTERIAN HEALTH PLAN PRINCIPAL PRIVATE PAY PYRAMID RESERVE NATIONAL INS CO ROYAL NEIGHBORS OF AMERICA SECURE HORIZONS SECURITY LIFE SOUTHWEST ADMINISTRATORS SOUTHWEST SERVICE ADMINISTRATORS SPECTERA STANDARD LIFE AND ACCIDENT STARMARK State farm SUMMIT TALL TREE ADMINISTRATORS THE MEGA LIFE AND HEALTH INSURANCE CO. THRIVENT FINANCIAL TRI CARE UMR UMWA HEALTH AND RETIREMENT UNITED AMERICAN UNITED COMMERCIAL TRAVELERS OF AMERICA UNITED FOOD AND COMMERCIAL UNITED HEALTH CARE UNITED HEALTH CARE COMMUNITY PLAN UNITED HEALTH CARE IPA UNITED HEALTH COMPANY UNITED HEALTHCARE ARIZONA RETIREMENT UNITED HEALTHCARE DUAL COMPLETE UNITED TEACHERS ASSOCIATES UNIVERSAL HEALTH CARE VISION CARE DIRECT VISION SERVICE PLAN WAKELY AND ASSOCIATES WELL CARE WOODMEN OF THE WORLD YAVAPAI APACHE TRIBE YAVAPAI TRUST
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 ADVANTRA FREEDOM ADVENTIST RISK MANAGEMENT AETNA AETNA LIFE INSURANCE AETNA MEDICARE AFLAC AGC TRUST OF MONTANA AHCCCS AMERIBEN/IEC GROUP AMERICAN BENEFIT PLAN ADMIN. American Continental AMERICAN FAMILY AMERICAN REPUBLIC AMERICAN RETIREMENT APWU ARIZONA PIPE TRADES HEALTH AND WELFARE ASPEN EDUCATION GROUP ASSURANT HEALTH AVESIS AVMA AZ HEALTH CARE COST CONTAINMENT BANKERS LIFE Banner Health BANNER HEALTH BASHAS BENEFIT TRUST BLUE CROSS BLUE SHIELD BLUE CROSS BLUE SHIELD OF MICHIGAN BLUE MEDICARE ADVANTAGE CAREMARK CHAMPVA CIGNA COLONIAL PENN COLUMBIAN MUTUAL COMMONWEALTH OF MASS. COPPER CANYON ACADEMY CSI DAVIS VISION DESERET SECURE PLUS DESERT CANYON EQUITABLE AND YOU ESSENTIAL STAFFCARE EVERANCE FIRST CHOICE HEALTH FIRST HEALTH FISERV HEALTH FOREIGN SERVICE BENEFIT PLAN GEHA GERBER LIFE INSURANCE GILSBAR GOLDEN RULE GPM LIFE GREAT WEST HEALTH NET HEALTHCARE GROUP OF ARIZONA HMA HOP ADMINISTRATION UNIT HUMANA HUMANA MILITARY LIFEWISE LIONS CLUB MAIL HANDLERS BENEFIT PLAN MBA OF MARYLAND INC. MEDI-SHARE MEDICARE MEDICO MEDIPLUS MERITAIN HEALTH MOUNTAIN STATES MOUNTAIN STATES ADMINISTRATIVE MPI HEALTH PLAN MSGA MUTUAL OF OMAHA NACOG/ AREA AGENCY ON AGING NATIONAL AUTOMATIC SPRINKLER INDUSTRY NATIONAL AUTOMATIC SPRINKLER WELFARE FUND NAVAHCS NAVAJO NATION EMPLOYEE BENEFIT PLAN NONE Northwest Administrators NORTHWEST ADMINISTRATORS ODS operating engineers bc/bs OPERATING ENGINEERS HEALTH AND WELFARE PACIFIC CARE PACIFIC CARE (ARIZONA RETIREMENT) PALMETTO GBA Ph PHOENIX HEALTH PLANS PHYSICIANS CARE PHYSICIANS MUTUAL PREMERA PRESBYTERIAN HEALTH PLAN PRINCIPAL PRIVATE PAY PYRAMID RESERVE NATIONAL INS CO ROYAL NEIGHBORS OF AMERICA SECURE HORIZONS SECURITY LIFE SOUTHWEST ADMINISTRATORS SOUTHWEST SERVICE ADMINISTRATORS SPECTERA STANDARD LIFE AND ACCIDENT STARMARK State farm SUMMIT TALL TREE ADMINISTRATORS THE MEGA LIFE AND HEALTH INSURANCE CO. THRIVENT FINANCIAL TRI CARE UMR UMWA HEALTH AND RETIREMENT UNITED AMERICAN UNITED COMMERCIAL TRAVELERS OF AMERICA UNITED FOOD AND COMMERCIAL UNITED HEALTH CARE UNITED HEALTH CARE COMMUNITY PLAN UNITED HEALTH CARE IPA UNITED HEALTH COMPANY UNITED HEALTHCARE ARIZONA RETIREMENT UNITED HEALTHCARE DUAL COMPLETE UNITED TEACHERS ASSOCIATES UNIVERSAL HEALTH CARE VISION CARE DIRECT VISION SERVICE PLAN WAKELY AND ASSOCIATES WELL CARE WOODMEN OF THE WORLD YAVAPAI APACHE TRIBE YAVAPAI TRUST
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 select any medical problems you have had:

Good health Arthritis Asthma Diabetes HBP Headaches High Cholesterol Heart Condition HX Of Drug/Alcohol Abuse Inflammatory Bowel Disease Smoking Seizure Disorder Thyroid Disease Preg "Now" Nursing Diagnosed As HIV+ Other	Good health Arthritis Asthma Diabetes HBP Headaches High Cholesterol Heart Condition HX Of Drug/Alcohol Abuse Inflammatory Bowel Disease Smoking Seizure Disorder Thyroid Disease Preg "Now" Nursing Diagnosed As HIV+ Other	Good health Arthritis Asthma Diabetes HBP Headaches High Cholesterol Heart Condition HX Of Drug/Alcohol Abuse Inflammatory Bowel Disease Smoking Seizure Disorder Thyroid Disease Preg "Now" Nursing Diagnosed As HIV+ Other
Good health Arthritis Asthma Diabetes HBP Headaches High Cholesterol Heart Condition HX Of Drug/Alcohol Abuse Inflammatory Bowel Disease Smoking Seizure Disorder Thyroid Disease Preg "Now" Nursing Diagnosed As HIV+ Other	Good health Arthritis Asthma Diabetes HBP Headaches High Cholesterol Heart Condition HX Of Drug/Alcohol Abuse Inflammatory Bowel Disease Smoking Seizure Disorder Thyroid Disease Preg "Now" Nursing Diagnosed As HIV+ Other	Good health Arthritis Asthma Diabetes HBP Headaches High Cholesterol Heart Condition HX Of Drug/Alcohol Abuse Inflammatory Bowel Disease Smoking Seizure Disorder Thyroid Disease Preg "Now" Nursing Diagnosed As HIV+ Other

Injuries, Surgeries, Hospitalization:

Pregnant Or Nursing:	No Yes Unsure Other	Recent Tetanus Shot:	Yes No Other	Notes:
Primary Care Physcian:		Last Visit:	1 week 1 month 3 months 6 months 1 year 2 years Other	Reason For Visit:	Annual Check up Post Op Contact Lens Fit Other
Over The Counter Medications:	None Asprin Acetomenophin Ibuprofen Other	Vitamins:	None Multi A E C Zinc Xanten Lutein B12 Other

Medications:		No current medications
Drug Allergies:		No known drug allergies

Family Medical History

None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid Other	Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Disease Thyroid Back Problems Other	Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Disease Thyroid Back Problems Other
Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Disease Thyroid Back Problems Other	Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Disease Thyroid Back Problems Other	Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Disease Thyroid Back Problems Other

Family Patients:

Occupation:

Student Stay at home mom Unemployed Police officer Teacher Nurse Salesman Firefighter Engineer Lawyer construction Accountant Other

Hobbies:

Astronomy Art Baseball Boating Basketball Cooking Crafts Dancing Diving Football Fishing Golf Gardening Horseback Riding Hunting Models Needlepoint None Painting Photography Piano Playing Reading Running Roller Blading Softball Sewing Skiing Soccer Swimming Tennis Video Games Woodworking Other

Smoking Status:	Never Smoker Current every day smoker Current some day smoker Former smoker Smoker, currernt status unknown Unknown if ever smoked Other	Type:	None Cigaretts Chewing Tobacco Cigars Other	How Long:
Alcohol:	No Yes Occasionally Socially Other	Type:	None Beer Wine Hard Liquor Other	How Long:
Illegal Drugs:	No Yes Other	Type:		How Long:
STD:	None Gonorrhea Syphilis Hepatitis HIV TB Other

Review of Systems

GENERAL: Fever, weight loss, weight gain, fatigue?	None Negative weight gain weight loss fever fatigue Other
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat	None Allergies Sinus Problems Chronic Cough Dry Throat / Mouth Hard of Hearing Ear infection Other
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease	None Vascular Disease HBP Heart Surgery Mitral valve prolapse Ischemic heart disease Congestive heart failure Arrhythmia Atherosclerosis Other
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD	None Asthma Bronchitis Emphysema COPD Other
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence	None Kidney disease frequent urination impotence painful urination Prostate problems yellow jaundice Other
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury	None joint pain stiffness swelling cramps arthritis Other
SKIN: growths, rashes, acne	None pimples, warts growths rash Eczema Psoriasis acnea Other
NEUROLOGICAL: Headaches, migraines, seizures	None numbness, paralysis headache seizures migraines Other
PSYCHIATRIC: Depression, Anxiety, Insomnia	None anxiety depression insomnia bipolar Schizophrenia Other
ENDORCRINE: Thyroid, Diabetes	None diabetes hypothyroid hyperthoyroid Thyroid removed Other
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems	None bleeding cholestrolemia anemia Other
ALLERGIC/IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus	None seasonal sneezing swelling redness itching hives lupus Rheumatoid HIV AIDS Other
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux	None Diarrhea Constipation Ulcer Acid Reflux IBS Crohn's disease Ulcerative Colitis Other

Ocular History

Ocular History:	None Itching Burning, Stinging Amblyopia Eye Injuries Eye Surgery Flashes Of Light Floaters Strabismus Cataracts Glaucoma Retinal Disorders Corneal Neovascularization Dry Eye Macular Degeneration Diabetic Retinopathy Allergic Conjuctivitis Other	Eye Meds:	None Cromolyn NA 4% Visine Patanol Xalatan Travatan rewetting drops Elestat Vigamox Alphagan Refresh Theratears Genteal Pred Forte Lotemax Alrex Systane Blink Other
Last Eye Exam:	1 year 2 years 3 years 1st eye exam Other	Doctor/Location:

Glaucoma:	No Sibling Grandparent Mother Father Aunt Uncle Cousin Child MGM MGF Great Grandparent Other	Cataracts:	No Sibling Grandparent Mother Father Aunt Uncle Cousin Child MGM MGF Great Grandparent Other
Macular Degen:	No Sibling Grandparent Mother Father Aunt Uncle Cousin Child MGM MGF Great Grandparent Other	Retinal Detach:	No Sibling Grandparent Mother Father Aunt Uncle Cousin Child MGM MGF Great Grandparent Other
Crossed/Lazy:	No Sibling Grandparent Mother Father Aunt Uncle Cousin Child MGM MGF Great Grandparent Other

Primary Vision Correction:	None Glasses-Full Time Glasses-Readers Only Contacts - Soft RGPs PMMA Other	Back up specs?	Yes No Other
Planning to get new glasses?	Yes No Other	Type of CLs worn in past:	None Air Optix aqua Air Optix for Astig Air Optix Multifocal Dailies aqua Dailies Toric N & D Freshlook AV Oasys AV Oasys for Astig AV adv AV Oasys for Presby AV 1-Day Moist Acuvue 2 Biofinity Biofinity Toric Proclear Proclear Toric Proclear MF SL66 SL 66 Toric SL 66 MF Freq 55 Purevision Purevision 2 HD Purevison Toric Purevision MF Bella Other
Wear Time:	8 - 10 Hours All day Occ. Overnight Extended Other	Cleaner:	Optifree Clear Care Boston Renu Biotrue Store Brand Aquify Other
Disposal:	2 weeks monthly daily weekly yearly Other

Decreased distance vision?	Yes No Other	Decreased near vision?	Yes No Other	Decreased computer vision?	Yes No Other
Night glare or haloes?	Yes No Other	Dry eyes?	Yes No Other	Itchy eyes?	Yes No Other
Red Eyes?	Yes No Other	Burning or stinging?	Yes No Other	Sensitive to light?	Yes No Other
Tearing or watering?	Yes No Other	Do you see flashes of light?	Yes No Occasional Constant Other	Do you see floaters?	Yes No Occasional Constant Other
Do you have headaches?	Yes No Other	If yes, how often?	Daily Weekly Monthly Few times a year Other	where?	Frontal Temporal Behind eyes Back of head All over Other

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