New Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
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:

Primary

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:
SSN:
Employer/School:

Secondary

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:
SSN:
Employer/School:

Tertiary

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:
SSN:
Employer/School:

Medical History

Medical History


Please choose from the menu options or select "Other" to type in multiple choices or your own text. Thank you!

What is the MAIN reason for your visit?
My Primary Care Physician is: (Name, Phone Number)         My Preferred Pharmacy is : (Name, Phone Number)
       

Do you smoke regularly?                 Height       Insurance regulations require that we record your weight and height
Do you drink alcohol regularly?                 Weight


YOUR MEDICAL HISTORY:

Have you had any problems with the following:

Diabetes Sarcoidosis or Lupus
Cold Sores Bleeding Disorders
Allergies or Autoimmune Problems Stroke
Weakness or Paralysis Respiratory (asthma, emphysema)
Fever HIV
Rapid weight loss or gain Thyroid Problems
Cancer Muscles, Bones, or Joint Problems
Other health problems?


DO YOU OR ANY OF YOUR BLOOD RELATIVES HAVE HEALTH PROBLEMS IN ANY OF THE FOLLLOWING AREAS?

Blindess Retinal Detachment
Glaucoma Cataracts
Macular Degeneration Strabismus (eye turn)
Partial Loss of Vision (central and/or side) Amblyopia (lazy eye)


YOUR EYES: Do you have any of these symptoms?

Blurry Vision with glasses or contacts Burning or Itching
Distorted Vision Eye Pain or Soreness
Double Vision with glasses or contacts Dry Eyes
Red Eyes Flashes of Light
Discharge (watery, mucous) Floaters
Sandy or Gritty feeling Shadows or Curtains
Glare, Light Sensitivity, or Halos Watery Eyes
Loss of Vision (central and/or side) Bump or Growth on Eyelid


Have you had any of the following?

Eye Surgery Eye Disease Eye Injury
Other Eye Problems
Are you allergic to any medications? If yes, please list.
List CURRENT Medications (including tablets, injections, eye drops, birth control, hormones, and antihistimines)

Submit Data


The above information regarding my personal medical history is true and correct to the best of my knowledge.

Patient (or Guardian) SignatureDate

After Completing All Forms Submit Data on Final Tab