New Patient Form
Demographics
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Rev.
Fr.
Miss
Address:
City:
State/ZipCode
OH
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
OK
OR
PA
RI
SC
SD
TN
TX
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
Email
Birthday
Sex
Male
Female
Marital Status
Single
Married
Separated
Divorced
Widowed
Unknown
Primary Doctor
No Doctor Assigned
Dr. Kenkel, Timothy
Dr. Cleary, Julie
Dr. Burcham, Marc
Dr. PLEIMAN, MICHELLE
Dr. HECHT, STEVE
Primary
Insurance Information
Insurance Name:
None
Aetna
Anthem
Caresource
Eyemed
Humana HMO
Humana PPO
Humana Vision
Medicare
Superior Vision
United Health Care
United Medical Resource
VSP vision service plan
Insurance ID:
Insurance Policy Group:
Primary on Account
Name:
Last, First MI
Relationship to Insured:
Spouse
Child
Other
Phone Number:
Birthday:
Last 4 of SSN:
Ocular History
Last Eye Exam:
Never
1 year
2 years
3 years
4 years
5 years
Unknown
Greater than 5 years
Doctor:
or Place:
Apex
Cincinnati Eye Institute
Eyemart
Midwest
TriState Centers for Sight
Walmart
Wing Eyecare
Unknown
Other
Ocular History: List of Surgeries, Amblyopia/Lazy Eye, Stabismus/Eye Turn, Significant Trauma, Cataracts, Glaucoma, Macular Degeneration, History of Wearing Contacts
Do you use any of the following eye medications?
None
Other
Visine
Patanol
Alphagan
Timolol
Xalatan
Travatan
rewetting drops
Elestat
Vigamox
Refresh
Theratears
Genteal
Pred Forte
Lotemax
Alrex
Systane
Blink
Primary Vision Correction:
None
Glasses-Full Time
Glasses-Readers Only
Contacts - Soft
RGPs
Glasses-Distance Only
If you primarily wear contact lenses, do you have back up glasses?
Yes
No
Are you planning to get new glasses?
Yes
No
FAMILY OCULAR HISTORY:
Glaucoma:
No
Mother
Father
Brother
Sister
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
More than 1 family member
Cataracts:
No
Mother
Father
Brother
Sister
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
More than 1 family member
Macular Degeneration:
No
Mother
Father
Brother
Sister
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
More than 1 family member
Retinal Detach:
No
Mother
Father
Brother
Sister
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
More than 1 family member
Crossed / Lazy:
No
Mother
Father
Brother
Sister
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
More than 1 family member
CONTACT LENS INFORMATION:
Check this box if you want a Contact Lens Evaluation at your Exam
What is your current brand or type of contact lenses?
Unknown
New Wearer
RGP
Acuvue 2
Acuvue Advance
Acuvue Oasys
Air Optix
Avaira
Biofinity
Proclear
Purevision
Purevision 2
Acuvue 1 day Moist
Acuvue Trueye
Biotrue
Dailies AQP
Dailies Total One
Proclear Dailies
Soflens Dailies
Other:
Distance Only
Monovision
Multifocal
How would you rate the comfort?
Good
Fair
Poor
Dryness at end of day
How often do you sleep in your contact lenses?
Never
Rarely
6 nights a week
5 nights a week
4 nights a week
3 nights a week
2 nights a week
1 night a week
Every night
30 nights continuously
How often do you throw away your contacts and put in a new pair?
2 weeks
monthly
daily
weekly
yearly
Medical History
Occupation:
Race: Required to ask per the Affordable Care Act
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Declining to answer or unknown
Preferred Language: Required to ask per the Affordable Care Act
English
French
German
Spanish
Other
Ethnicity: Required to ask per the Affordable Care Act
Non Hispanic or Latino
Hispanic or Latino
Declining to answer or unknown
Who is your Primary Care Physcian:
Last Visit to Primary Care Doctor:
1 week
1 month
3 months
6 months
1 year
2 years
Problems List: Examples include Diabetes, Hypertension, High Cholesterol, Multiple Sclerosis, Sarcoidosis, Lupus, Osteo Arthritis, Rheumatoid Arthritis, Cancer, Hypothyroid, Hyperthyroid, Cancer, COPD, Asthma, Sickle Cell
Medications: Please list all current medications and their dosages
No current medications
OTC:
None
Asprin
Acetomenophin
Ibuprofen
Allegra
Claritin
Zyrtec
Other
Vitamins:
None
A
E
C
Zinc
Xanten
Multivitamin
Lutein
AREDS
Other
Allergies: Please list all current known allergies, and your reaction to them
No Known Allergies
Pregnant Or Nursing:
No
Unsure
Pregnant
Nursing
Any Complications from Pregnancy:
None
Preclampsia
Gestational Diabetes
Significant Injuries, Surgeries, Hospitalization
Smoking Status:
Never Smoker
Current every day smoker
Current some day smoker
Former smoker
Smoker, currernt status unknown
Unknown if ever smoked
How Long have or did you smoke for:
FAMILY MEDICAL HISTORY:
Examples: Diabetes, Heart Disease, Cancer, Kidney, Thyroid, Other:
None
Adopted
Diabetes
Cancer
Cardiovascular Disease
Kidney Disease
Thyroid
Family Medical History
Family Medical Histor
Family Medical History
Family Medical History
Family Medical History
Submit Data
After Completing All Forms Submit Data on Final Tab