New Patient Form

Demographics

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

Address: City: State/ZipCode 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 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 SSN Email Birthday Occupation Sex Male Female Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix

Address

City	State	ZipCode
	TX

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Primary Vision Insurance

Insurance Information

Insurance Name:	None Aetna Medical ALWAYS CARE-STARMOUNT Amerigroup (Block Vision) Avesis Block Vision Blue Cross Blue Shield of Texas Boon-Chapman Cigna Medical Cigna Vision (VSP) CoreSource Davis Vision Humana Medical Let's Go See Voucher Medicare Metlife (VSP) National Vision Administrators OptiCare RH Administrators, Inc Superior Vision Tricare Triwest United Health Care Medical United Health Care Vision (Spectera) Vision Discount Program VSP WellCare Health Plans
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:	None Aetna Medical ALWAYS CARE-STARMOUNT Amerigroup (Block Vision) Avesis Block Vision Blue Cross Blue Shield of Texas Boon-Chapman Cigna Medical Cigna Vision (VSP) CoreSource Davis Vision Humana Medical Let's Go See Voucher Medicare Metlife (VSP) National Vision Administrators OptiCare RH Administrators, Inc Superior Vision Tricare Triwest United Health Care Medical United Health Care Vision (Spectera) Vision Discount Program VSP WellCare Health Plans
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

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Primary Medical Insurance

Insurance Information

Insurance Name:	None Aetna Medical ALWAYS CARE-STARMOUNT Amerigroup (Block Vision) Avesis Block Vision Blue Cross Blue Shield of Texas Boon-Chapman Cigna Medical Cigna Vision (VSP) CoreSource Davis Vision Humana Medical Let's Go See Voucher Medicare Metlife (VSP) National Vision Administrators OptiCare RH Administrators, Inc Superior Vision Tricare Triwest United Health Care Medical United Health Care Vision (Spectera) Vision Discount Program VSP WellCare Health Plans
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:

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Reason for Visit

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

Reason for Visit:

distance vision blurry near vision blurry vision blurry distance and near red eye pain in eye loss of vision eye injury itchy eyes burning in eyes stinging in eyes dry eyes Diabetic eye exam annual doctor directed diabetic eye exam failed screening at school Other

Ocular History Itching Burning, Stinging Amblyopia Eye Injuries Eye Surgery Flashes Of Light Floaters Strabismus Cataracts Glaucoma Retinal Disorders None Other

Eye Meds:

None Cromolyn NA 4% Visine Patanol Xalatan Travatan rewetting drops Elestat Vigamox Alphagan Refresh Theratears Genteal Pred Forte Lotemax Alrex Systane Blink Other

Last Eye Exam:

1 year 2 years 3 years Other

Doctor:

Doesn't Remember Dr. Kessner, Marc Other

Primary Vision Correction:

None Glasses-Full Time Glasses-Readers Only Contacts - Soft RGPs Other

Type of CLs worn in past:

None Disposable Conventional RGP Other

Family Ocular History:

Glaucoma:

No Parents Sibling Grandparent Other

Cataracts:

No Parents Siblings Grandparent Other

Macular Degen:

No Parents Siblings Grandparent Other

Other:

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Medical History

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

Surgeries or hospitalizations in the last 2 years:
Primary Care Physician:	Doesn't Have One Doesn't Remember Other         Last Visit: 1 week 1 month 3 months 6 months 1 year 2 years Other         Pregnant Or Nursing: No Yes Unsure Other

Please list all prescribed medications:

Over The Counter Medications:

None Asprin Acetomenophin Ibuprofen Other

Vitamins:

None A E C Zinc Xanten Lutein multivitamins Other

Family Medical History:

None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid Other

None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid Other

None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid Other

None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid Other

None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid Other

None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid Other

Social History:

Smoking Status:	Never Smoker Current every day smoker Current some day smoker Former smoker Smoker, currernt status unknown Unknown if ever smoked Other	Type:	None Cigarettes Chewing Tobacco Other	How Long:
Alcohol:	No Yes Occasionally Socially Other	Type:	None Beer Wine Hard Liquor Other	How Long:
Recreational Drugs:	No Yes Other	Type:
STD:	None Gonorrhea Syphilis Hepatitis HIV TB Other

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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:	None Fever Weight Loss Weight Gain Fatigue Other (ex. Fever, Weight Loss, Weight Gain, Fatigue)
Ear/Nose/Throat:	None Allergies Sinus Problems Chronic Cough Dry Throat / Mouth Hard of Hearing Other (ex. Allergies, Sinus, Cough, Dry Mouth/Throat)
Cardiovascular	None Vascular Disease High BP Heart Surgery Other (ex. High BP, Heart Surgery, Vascular Disease)
Respiratory:	None Asthma Bronchitis Emphysema COPD Other (ex. Asthma, Bronchitis, Emphysema, COPD)
Genitourinary:	None Painful Urination Frequent Urination Impotence Yellow Jaundice Other (ex. Kidney Stones, Frequent Urination, Impotence)
Musculoskeletal:	None Joint Pain Stiffness Swelling Cramps Arthritis Other (ex. Arthritis, Joint Pains, Head or Neck Injury)
Skin:	None Pimples, Warts Growths Rash Other (ex. Growths, Rashes, Acne)
Neurological:	None Numbness, Paralysis Headache Seizures Migraines Other (ex. Headaches, Migraines, Seizures)
Psychiatric:	None Anxiety Depression Insomnia Other (ex. Depression, Anxiety, Insomnia)
Endocrine:	None Diabetes Type 1 Diabetes Type 2 Hypothyroid Hyperthyroid Other (ex. Thyroid, Diabetes)
Blood/Lymph:	None Bleeding Cholesterolemia Anemia Other (ex. Anemia, Cholesterol, Bleeding Problems)
Allergy/Immune:	None Hives Lupus Seasonal Allergies Other (ex. Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus)
Gastrointestinal:	None Diarrhea Constipation Ulcer Acid Reflux Other (ex. Diarrhea, Constipation, Ulcer, Reflux)

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