New Patient Form

Demographics

TitleFirstLastMISuffix
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Male Female
Primary Doctor Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode

Primary Vision Insurance

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
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:

Secondary Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary

Primary Medical Insurance

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
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:

Reason for Visit


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

Review of Ocular History:

Reason for Visit:

Ocular History
Eye Meds: Last Eye Exam: Doctor:

Primary Vision Correction:

Type of CLs worn in past:


Family Ocular History:
Glaucoma: Cataracts: Macular Degen: Other:


Medical History


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


Injuries, Surgeries, Hospitalization:
Primary Care Physcian:         Last Visit:         Pregnant Or Nursing:

Please list all prescribed medications:
Over The Counter Medications: Vitamins:

Family Medical History:

Social History:
Smoking Status: Type: How Long:
Alcohol: Type: How Long:
Illegal Drugs: Type:
STD:


Review of Systems


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

Do you currently have any of these problems?

General: (ex. Fever, Weight Loss, Weight Gain, Fatigue)
Ear/Nose/Throat: (ex. Allergies, Sinus, Cough, Dry Mouth/Throat)
Cardiovascular (ex. High BP, Heart Surgery, Vascular Disease)
Respiratory: (ex. Asthma, Bronchitis, Emphysema, COPD)
Genitourinary: (ex. Kidney Stones, Frequent Urination, Impotence)
Musculoskeletal: (ex. Arthritis, Joint Pains, Head or Neck Injury)
Skin: (ex. Growths, Rashes, Acne)
Neurological: (ex. Headaches, Migraines, Seizures)
Psychiatric: (ex. Depression, Anxiety, Insomnia)
Endocrine: (ex. Thyroid, Diabetes)
Blood/Lymph: (ex. Anemia, Cholesterol, Bleeding Problems)
Allergy/Immune: (ex. Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus)
Gastrointestinal: (ex. Diarrhea, Constipation, Ulcer, Reflux)


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