New Patient Form

Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Master Miss

Address: City: State/ZipCode CA AL AK AZ AR 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 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 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. Jackman, O.D., Janice P. Misc/Guardian

How did you find out about our office?:

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Master Miss

Address

City	State	ZipCode
	CA AL AK AZ AR 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 TX UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None Advantica Aetna Anthem Blue Cross Avesis Blue Shield of California Blue View Vision Blue Vision Cigna Cigna Vision Davis Vision Delta Health Systems eba&m EXCELVISION EYEMED First Health Network Guardian Health Net Humana Insurance Mandated Discount Medicare CA South - Medicare MES Vision MultiPlan New Insurance New Insurance OptumHealth Vision Claims Department Pacificare HMO Principal Life Insurance Co. SafeGuard Claims SDS Clinical Trials Spectera Superior Tricare UnitedHealthcare VPA VSP VSP Healthy Families
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 Advantica Aetna Anthem Blue Cross Avesis Blue Shield of California Blue View Vision Blue Vision Cigna Cigna Vision Davis Vision Delta Health Systems eba&m EXCELVISION EYEMED First Health Network Guardian Health Net Humana Insurance Mandated Discount Medicare CA South - Medicare MES Vision MultiPlan New Insurance New Insurance OptumHealth Vision Claims Department Pacificare HMO Principal Life Insurance Co. SafeGuard Claims SDS Clinical Trials Spectera Superior Tricare UnitedHealthcare VPA VSP VSP Healthy Families
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 Advantica Aetna Anthem Blue Cross Avesis Blue Shield of California Blue View Vision Blue Vision Cigna Cigna Vision Davis Vision Delta Health Systems eba&m EXCELVISION EYEMED First Health Network Guardian Health Net Humana Insurance Mandated Discount Medicare CA South - Medicare MES Vision MultiPlan New Insurance New Insurance OptumHealth Vision Claims Department Pacificare HMO Principal Life Insurance Co. SafeGuard Claims SDS Clinical Trials Spectera Superior Tricare UnitedHealthcare VPA VSP VSP Healthy Families
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?	Yes No Other	Height		Insurance regulations require that we record your weight and height
Do you drink alcohol regularly?	Yes No Other	Weight

YOUR MEDICAL HISTORY:

Have you had any problems with the following:

Diabetes	Yes No Other	Sarcoidosis or Lupus	Yes No Other
Cold Sores	Yes No Other	Bleeding Disorders	Yes No Other
Allergies or Autoimmune Problems	Yes No Other	Stroke	Yes No Other
Weakness or Paralysis	Yes No Other	Respiratory (asthma, emphysema)	Yes No Other
Fever	Yes No Other	HIV	Yes No Other
Rapid weight loss or gain	Yes No Other	Thyroid Problems	Yes No Other
Cancer	Yes No Other	Muscles, Bones, or Joint Problems	Yes No Other
High Blood Pressure	Yes No Other

Other health problems?

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

Blindess	Yes No Other	Retinal Detachment	Yes No Other
Glaucoma	Yes No Other	Cataracts	Yes No Other
Macular Degeneration	Yes No Other	Strabismus (eye turn)	Yes No Other
Partial Loss of Vision (central and/or side)	Yes No Other	Amblyopia (lazy eye)	Yes No Other

YOUR EYES: Do you have any of these symptoms?

Blurry Vision with glasses or contacts	Yes No Other	Burning or Itching	Yes No Other
Distorted Vision	Yes No Other	Eye Pain or Soreness	Yes No Other
Double Vision with glasses or contacts	Yes No Other	Dry Eyes	Yes No Other
Red Eyes	Yes No Other	Flashes of Light	Yes No Other
Discharge (watery, mucous)	Yes No Other	Floaters	Yes No Other
Sandy or Gritty feeling	Yes No Other	Shadows or Curtains	Yes No Other
Glare, Light Sensitivity, or Halos	Yes No Other	Watery Eyes	Yes No Other
Loss of Vision (central and/or side)	Yes No Other	Bump or Growth on Eyelid	Yes No Other

Have you had any of the following?

Eye Surgery

Yes No Other

Eye Disease

Yes No Other

Eye Injury

Yes No Other

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) Signature	Date