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 Interlocutory Legally Separated Married Never Married Polygamous Widowed	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Ansari MD, Irfan Dr. Harlan, OD, Aubrey	Misc/Guardian

Race:	Language:	Ethnicity:
American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Decline	English Spanish French Decline Arabic German French If other, please type in this box.	Hispanic or Latino Not Hispanic or Latino Unknown Decline

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:

Medical History

Medical Problems:
Good health Arthritis Asthma Diabetes HBP Headaches Heart Condition HX Of Drug/Alcohol Abuse Inflammatory Bowel Disease Smoking Seizure Disorder Thyroid Disease Preg "Now" Nursing Diagnosed As HIV+ Other	Diabetes HBP Heart disease Cancer Arthritis Lupus Kidney Thyroid Back Problems Other	Athritis Diabetes HBP Heart Disease Cancer Lupus Kidney Disease Thyroid Disease Back Problems Other	Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Thyroid Back Problems Other	Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Thyroid Disease Back Problems Other	Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Disease Thyroid Back Problems Other

Injuries, Surgeries, Hospitalization

None Other

Pregnant Or Nursing:
No Yes Unsure Other	Notes:

Last Visit:

1 week 1 month 3 months 6 months 1 year 2 years Other

OTC:

None Asprin Acetomenophin Ibuprofen Other

Vitamins:

None A E C Zinc Xanten Lutein Other

Family History	Relationship
None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid Other	Mother Father Brother Sister Grandmother Grandfather Uncle Aunt Cousin Child If other, please type in this box.
None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid Other	Mother Father Brother Sister Grandmother Grandfather Uncle Aunt Cousin Child If other, please type in this box.
None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid Other	Mother Father Brother Sister Grandmother Grandfather Uncle Aunt Cousin Child If other, please type in this box.
None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid Other	Mother Father Brother Sister Grandmother Grandfather Uncle Aunt Cousin Child If other, please type in this box.
None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid Other	Mother Father Brother Sister Grandmother Grandfather Uncle Aunt Cousin Child If other, please type in this box.
None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid Other	Mother Father Brother Sister Grandmother Grandfather Uncle Aunt Cousin Child If other, please type in this box.

Occupation:	Hobbies:
Student Police officer Teacher Nurse Salesman Firefighter Engineer Other	Astronomy Art Baseball Boating Basketball Cooking Crafts Dancing Diving Football Fishing Golf Gardening Horseback Riding Hunting Models Needlepoint None Painting Photography Piano Reading Running Roller Blading Softball Sewing Skiing Soccer Swimming Tennis Video Games Woodworking Other

Smoking Status:	Type:	How Long:
Never Smoker Current every day smoker Current some day smoker Former smoker Smoker, currernt status unknown Unknown if ever smoked Other	None Cigaretts Chewing Tobacco Other

Alcohol:	Type:	How Long:
No Yes Occasionally Socially Other	None Beer Wine Hard Liquor Other

>

Illegal Drugs:	Type:	How Long:	STD:
No Yes Other			None Gonorrhea Syphilis Hepatitis HIV TB Other

NKDANo current meds >

Ocular History
Disease	Eye	When	Procedure
1 None Cataract Glaucoma Macular Degeneration Retinal Detachment Amblyopia(Lazy Eye)	Right Eye Left Eye Both Eyes	Within last 6 months Between 6 months-1year Between 1-5years Between 5-15years ago more than 15 years ago	None Cataract Surgery Glaucoma Surgery Eyelid Surgery Lasik Surgery(for getting rid of glasses) Laser Treatment (YAG-after cataract suergery) Laser Treatment (for glaucoma) Laser Treatment (Retina laser for diabetes) Laser Treatment (unknown)
2 None Cataract Glaucoma Macular Degeneration Retinal Detachment Amblyopia(Lazy Eye)	Right Eye Left Eye Both Eyes	Within last 6 months Between 6 months-1year Between 1-5years Between 5-15years ago more than 15 years ago	None Cataract Surgery Glaucoma Surgery Eyelid Surgery Lasik Surgery(for getting rid of glasses) Laser Treatment (YAG-after cataract suergery) Laser Treatment (for glaucoma) Laser Treatment (Retina laser for diabetes) Laser Treatment (unknown)
3 None Cataract Glaucoma Macular Degeneration Retinal Detachment Amblyopia(Lazy Eye)	Right Eye Left Eye Both Eyes	Within last 6 months Between 6 months-1year Between 1-5years Between 5-15years ago more than 15 years ago	None Cataract Surgery Glaucoma Surgery Eyelid Surgery Lasik Surgery(for getting rid of glasses) Laser Treatment (YAG-after cataract suergery) Laser Treatment (for glaucoma) Laser Treatment (Retina laser for diabetes) Laser Treatment (unknown)
4 None Cataract Glaucoma Macular Degeneration Retinal Detachment Amblyopia(Lazy Eye)	Right Eye Left Eye Both Eyes	Within last 6 months Between 6 months-1year Between 1-5years Between 5-15years ago more than 15 years ago	None Cataract Surgery Glaucoma Surgery Eyelid Surgery Lasik Surgery(for getting rid of glasses) Laser Treatment (YAG-after cataract suergery) Laser Treatment (for glaucoma) Laser Treatment (Retina laser for diabetes) Laser Treatment (unknown)
5 None Cataract Glaucoma Macular Degeneration Retinal Detachment Amblyopia(Lazy Eye)	Right Eye Left Eye Both Eyes	Within last 6 months Between 6 months-1year Between 1-5years Between 5-15years ago more than 15 years ago	None Cataract Surgery Glaucoma Surgery Eyelid Surgery Lasik Surgery(for getting rid of glasses) Laser Treatment (YAG-after cataract suergery) Laser Treatment (for glaucoma) Laser Treatment (Retina laser for diabetes) Laser Treatment (unknown)

Medication List
Medication	Dosage	Month/Year Prescribed
1
2
3
4
5

Review of Systems

DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?

GENERAL: Fever, weight loss, weight gain, fatigue?	None Negative Fever Weight loss Weight gain Fatigue
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat:	None Allergies Sinus Problems Chronic Cough Dry Throat / Mouth Hard of Hearing
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease:	None Vascular Disease HBP Heart Surgery
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD:	None Asthma Bronchitis Emphysema COPD
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence:	None painful urination frequent urination impotence yellow jaundice
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury:	None joint pain stiffness swelling cramps arthritis
SKIN: growths, rashes, acne:	None pimples, warts growths rash
NEUROLOGICAL: Headaches, migraines, seizures:	None numbness, paralysis headache seizures migraines
PSYCHIATRIC: Depression, Anxiety, Insomnia:	None anxiety depression insomnia
ENDORCRINE: Thyroid, Diabetes:	None diabetes hypothyroid hyperthoyroid
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems:	None bleeding cholestrolemia anemia
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus:	None sneezing swelling redness itching hives lupus
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux:	None Diarrhea Constipation Ulcer Acid Reflux

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