New Patient/Returning Form --- Please fill out ALL TABS-Demographics, Insurance, Medical History

Office Phone 281-550-4141

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Primary Doctor Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Insurance 1

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:
Birthday:
Employer/School:

Insurance 2

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:
Birthday:
Employer/School:

Insurance 3

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:
Birthday:
Employer/School:

Medical History

Who May We Thank For Referring You?
Are Any Of Your Family Already Patients At Cypress Family Eyecare? If Yes, who?
Please List Any Hobbies:

Are You Interested In Contact Lenses?
Have You Ever Worn Contact Lenses?
What Type of Contact Lenses Have You Worn In The Past?
Brand of Contacts/Prescription?
Do You Have Back Up Glasses For Your Contact Lenses?

What Do You Normally Wear For Vision Correction?
Do You Have A Current Pair Of Sunglasses?
Do You Have A Current Pair Of Computer Only Or Office Only Glasses?

Do You Have Problems with Glare?
Are You Interested in Laser Vision Correction?
Do Your Eyes Sting, Burn, Itch, Or Feel Dry? Have You Had An Eye Injury Or Been Diagnosed With Cataracts, Lazy Eye, Retinal Problems, Or Gluacoma?
Do You Take Any Eye Drops? If Yes, Which?

Who Was Your Last Eye Doctor?
Who Is Your Primary Care Physician:

What Medications/Vitamins Do You Take By Mouth?
Do You Have a History Of Headaches? Arthritis? Asthma? Diabetes? High Blood Pressure? Heart Problems? Inflammatory Bowel Disease?
Seizures? Thyroid Problems? Do You Smoke? Are You Pregnant? Are You Nursing? Are You HIV+? If Yes, Please List Below.

General Eye/Health History

 YesNo
Headaches
Glare/Light Sensitivity
Styes/Eye Infection
Flashes/Floaters in Vision
Blurred Vision
Double Vision
Dry/Burning Eyes
Redness/Itching
Excess Tearing/Watering
Sandy/Gritty Feeling
 YesNo
Diabetes
Endocrine/Thyroid
Allergies/Hay Fever
High Blood Pressure
High Cholesterol
Blood/Lymph Condition
Gastrointestinal Illness
Kidneys/Bladder Condition
Skin Condition
Other

Does Anyone In Your Family Have/Had Diabetes? Lupus? Cancer? High Blood Pressure? Heart Problems? Auto-Immune Disease?
If Yes, Please List Below.
Does Anyone In Your Family Have/Had Glaucoma? Macular Degeneration? Retinal Detatachment? Other Retinal Disorders?
If Yes, Please List Below.

Do You Have Any Allergies Or Any Allergic Reaction To Medication?
Any Other Relevant Information?

Submit Data



If you have a preference, pelase choose below. If not, the doctor will discuss their recommendation with you today.

  • These photos offer an alternative to dilation of the eyes! They create a permanent record of the retinal/eye health. There is a screening fee of $35.00.
  • With these drops, your near vision will likely be blurry for 4-6 hours, and you will be light sensitive. Sunglasses are recommended and will be provided when needed. Patients are usually able to drive.
  • Without dilation or photos, the doctor is only able to see a small portion of the back of the eye. By choosing this you acknowledge that the eye health is not fully being examined.