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. DINH, KHUONG Misc/Guardian

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:

Primary

Insurance Information

Insurance Name:	None Always Vision Care EyeMed Eyetopia NVA SELFPAY SPECTERA UPRR Safety VBA Vision Benefits of America VERSANT DAVIS VERSANT SUPERIOR VSP Access Indemnity VSP Access Plan VSP Advantage Plan VSP Choice 2nd Pair VSP Choice Access VSP Choice Exam + VSP Choice Plan VSP Computer Visioncare VSP Designated Choice VSP Elements (VOUCHER) VSP Exam Only Plan VSP Exam Plus VSP Exam Plus Allowance VSP Protec Safety VSP Regional Network Plan VSP Repair VSP Safety Eyecare VSP Signature VSP Signature Plan 2nd Pair VSP Value Plan VSP Vision Savings Pass
Insurance Plan:
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 Always Vision Care EyeMed Eyetopia NVA SELFPAY SPECTERA UPRR Safety VBA Vision Benefits of America VERSANT DAVIS VERSANT SUPERIOR VSP Access Indemnity VSP Access Plan VSP Advantage Plan VSP Choice 2nd Pair VSP Choice Access VSP Choice Exam + VSP Choice Plan VSP Computer Visioncare VSP Designated Choice VSP Elements (VOUCHER) VSP Exam Only Plan VSP Exam Plus VSP Exam Plus Allowance VSP Protec Safety VSP Regional Network Plan VSP Repair VSP Safety Eyecare VSP Signature VSP Signature Plan 2nd Pair VSP Value Plan VSP Vision Savings Pass
Insurance Plan:
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 Always Vision Care EyeMed Eyetopia NVA SELFPAY SPECTERA UPRR Safety VBA Vision Benefits of America VERSANT DAVIS VERSANT SUPERIOR VSP Access Indemnity VSP Access Plan VSP Advantage Plan VSP Choice 2nd Pair VSP Choice Access VSP Choice Exam + VSP Choice Plan VSP Computer Visioncare VSP Designated Choice VSP Elements (VOUCHER) VSP Exam Only Plan VSP Exam Plus VSP Exam Plus Allowance VSP Protec Safety VSP Regional Network Plan VSP Repair VSP Safety Eyecare VSP Signature VSP Signature Plan 2nd Pair VSP Value Plan VSP Vision Savings Pass
Insurance Plan:
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

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Last Eye Exam:

Last Eye Doctor:

Unknown Dinh Lens Crafter's Dr. Target Dr. Wal-Mart Dr. Visionworks Dr. Sears Dr. EyeMart Express Dr. Chan Craft Barton Nhan Gill Walz Lawson Other

Glasses Wearer?	No Yes Other	Glasses Type:	Single Vision Lined Bifocal No-Line Bifocal Other
RX Sunglasses?	No Yes Other	RX Computer Glasses?	No Yes Other
CL Wearer?	No Yes Other	Type of CLs worn in past:	No CL Hx Disposables Extended Wear Gas Permeables Gas Perm Bifocals Gas Perm Bitorics Gas Perm FS Toric Monovision - Soft Monovision - Disposables Monovision - Gas Perm Soft Daily Wear Soft Torics Other
Sleep in Contacts?	No Yes Sometimes Other

Eye Health History: Diseases, Injuries, Infections, Surgeries, etc:

None Abrasion Blind Eye Cataract - OU Cataract - OD Cataract - OS Conjunctivitis Glaucoma IOL - OU IOL - OD IOL - OS Metal in Eye Ptosis Retinal Detach Weak Eye Lazy Eye Eyelid Surgery Other

Eye Specialist:

Krishnan Majka Agarwal Spengler Avet Gullapalli Campbell Sohocki Dietze Saenz Bishop Kuffel Dugan Nisbet Hunsaker Sahadi Other

Medications:

Medication/Other Allergies:

NKDA Seasonal Allergies Erythromycin Iodine Pollen PCN Sulfa Codeine Tetanus Other

Health History:

Family Health History:	None Known Diabetes II Diabetes I HBP Heart Dz Chol Cancer Stroke Allergies Asthma Hay Fever Eczema Thyroid Migraines Lupus TB Anemia Hepatitis Gallbladder dz Kidney dz Arthritis Shingles Seizures Bell's Palsy Epilepsy HIV+ Psycho. cond. Learning cond. Other	Family Eye History:	None Known Blur dist Blur near Blur comp Eye strain HAs Dry Burn Watery Itchy Red Light sens Eye discharge Double Twitch Poor night Halos Floaters/spots Flashes Vision loss Lazy Poor color Styes Cataracts Glaucoma Mac Deg Blindness Other
Alcohol, Tobacco, Rec. Drug Use:	Denies any alcohol, tobacco or drug use Alcohol use Tobacco use Rec. Drug use Other	Digital Device Use hrs/day:
Hobbies:	Arts and Crafts Baseball Basketball Boating Bowling Cooking Cycling Dancing Excercising Fishing Football Golf Gardening Horses Hunting Jogging Lawn Work None Outdoors Painting Photography Piano Pogs Reading Running Sailing Scuba Sewing Skiing Soccer Softball Swimming Tennis T.V. Video Games Wake Boarding Weights Woodworking Other	Daily Environment:	Hazardous Outdoor Office Medical Other

Review of Systems

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

Ears, Nose, Throat:	None dry mouth cough ear ache hard of hearing stuffy nose Other
Cardiovascular:	None High BP heart dz racing pulse Other
Respiratory:	None asthma congestion short of breath wheezing Other
Genital, Kidney, Bladder:	None frequent urination impotence painful urination yellow jaundice Other
Muscles, Bones, Joints:	None arthritis cramps joint pain stiffness swelling Other
Skin:	None growths pimples, warts rash Other
Neurological:	None headache numbness, paralysis seizures Other
Psychiatric:	None anxiety depression insomnia Other
Endocrine:	None diabetes hypothyroid Other
Blood/Lymph:	None anemia bleeding cholestrolemia Other
Allergic/Immunologic:	None hives itching lupus redness sneezing swelling Other
Pregnant/Nursing:	N/A Pregnant Nursing Other

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