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: 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 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:

Ocular History

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Personal Ocular History

Last Eye Exam:

<1year 1-2 years 2-5 years >5 years Other

Last Eye Doctor:

Dr. Steven Lessley, O.D. Doesn't Remember Never Dr Gary Smith, O.D. Dr William Adkins, O.D. Dr Bruce Potter, O.D. Dr Shahrzad Shahriary, O.D. Lens Crafters Wal-Mart Target Dr Kaila Gurjeet, O.D. Other

Eye Surgery:	No Yes Other	Eye Injury:	No Yes Other	Glaucoma:	No Yes Other	Cataracts:	No Yes Other
Macular Degeneration:	No Yes Other	Eye Turn:	No Yes Other	Retinal Detachment:	No Yes Other	Other Eye Conditions:	No Yes Other

Notes:

Primary Vision Correction:	None Glasses-Full Time Glasses-Readers Only Glasses-Distance Only Contacts - Soft Contacts-Monovision Contacts with overwear readers Rigid Contact Lenses OTC readers Other	Back up specs?	Yes No Other	Wants new glasses?	Yes No Other
Current or Past Contact Lens Type:	None Daily Disposable 2 week Disposable 1 Month Planned Replacement Conventional 3 Month Planned Replacement Colored Rigid Contact Lenses Daily Wear Occasional Extended Wear Continuous Wear Other	Contact Lens Solutions:	Clear Care Opti-Free PureMoist Opti-Free Replenish Opti-Free Express Biotrue Renu PeroxiClear Boston Advance Boston Original Boston Simplus Other

NOTES:

Demographics

Race:

White Black or African American Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Other Race Patient Declined to Specify Other

Ethnicity:

Hispanic or Latino Not Hispanic or Latino Other Patient Declined to Specify Other

Preferred Language:

English Spanish Portuguese French German Chinese Japanese Russian Italian Declined Other

Height:Ft.

In.

Weight:Lbs.

Medical History

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Family Medical History

Glaucoma:	None 1 Parent 2 Parents 1 Grandparent 2 Grandparents 1 Sibling Multiple Siblings Other	Eye Turn/Lazy:	None 1 Parent 2 Parents 1 Grandparent 2 Grandparents 1 Sibling Multiple Siblings Other
Cataracts:	None 1 Parent 2 Parents 1 Grandparent 2 Grandparents 1 Sibling Multiple Siblings Other	Diabetes:	None 1 Parent 2 Parents 1 Grandparent 2 Grandparents 1 Sibling Multiple Siblings Other
Macular Degeneration:	None 1 Parent 2 Parents 1 Grandparent 2 Grandparents 1 Sibling Multiple Siblings Other	High Blood Pressure:	None 1 Parent 2 Parents 1 Grandparent 2 Grandparents 1 Sibling Multiple Siblings Other
Retinal Detachment:	None 1 Parent 2 Parents 1 Grandparent 2 Grandparents 1 Sibling Multiple Siblings Other	Other:	None 1 Parent 2 Parents 1 Grandparent 2 Grandparents 1 Sibling Multiple Siblings Other

Patient Medical History

Current Pharmacy

Academic Performance High School or Younger: Excellent Above Average Average Below Average Poor

Primary Care Physcian:

Doesn't Have One Doesn't Remember Dr. Riba Akhavon, M.D. Dr. Frank Alvarez, M.D. Dr. Ching-Tsung Chiu, M.D. Dr. Jatinder Chopra, M.D. Dr. Felix Trapse, M.D. Dr. David Gallardo, M.D. Dr. J R Grandeh, M.D. Dr. Parul Gupta, M.D. Dr. Susan Haack, M.D. Dr. Prem Kamboj, M.D. Dr. Parmod Kumar, M.D. Dr. Samuel Kuo, M.D. Dr. Jon Miyakawa, M.D. Dr. Robert Orth, M.D. Dr. Anil Patel, M.D. Dr. Asit Shah, M.D. Dr. Shashi, M.D. Dr. David Tenn, M.D. Dr. Tom Evans, M.D. Dr. Pradeep Kamboj, M.D. Dr. Arnold Weldon, M.D. Other

Specialist:

Drug Allergies:       No known drug allergies	Current Medications:       No meds

Pregnant/Nursing

Yes No Other

Vitamins:

None General Multi-Vitamin Fish Oil (Omega 3) Ocuvite Adult 50+ Ocuvite Eye & Multi Ocuvite Lutein 25 PreserVision AREDS2 PreserVision AREDS PreserVision AREDS Lutein I-Caps Lutein & Omega 3 I-Caps AREDS I-Caps MV Centrum Centrum Silver Other

Over the Counter Meds:

None Asprin Tylenol (Acetaminiphen) Advil (Ibuprofen) Motrin (Ibuprofen) Aleve (Naproxen) Claritin (Loratidine) Zyrtec (Cetirizine) Allegra (Fexofenadine) Benadryl (Diphenhydramine) Sudafed (Pseudoephedrine) Other

Injuries, Surgeries, Hospitalization
Notes:

Diabetic History

Type:	Type 2 Type 1 Prediabetes Gestational Other	Insulin:	Yes No Other	Oral Meds:	Yes No Other	Controlled:	Yes No Other
When Diagnosed:		Last BS:		Last Hg A1c:		Date of Hg A1c:

Social History

Occupation:

Student Police officer Teacher Nurse Salesman Firefighter Engineer Correctional Officer Farmer Dairy Worker Production Accountant Book Keeper Bus Driver CA Highway Patrol Counselor Custodian Disabled Instructional Aide Maintenance Mechanic Medical Assistant Retired Self Employed Other

Hobbies:

Astronomy Art Baseball Boating Basketball Cooking Crafts Dancing Diving Football Fishing Golf Gardening Horseback Riding Hunting Models Needlepoint None Painting Photography Piano Reading Running Roller Blading Softball Sewing Skiing Soccer Swimming Tennis Video Games Woodworking Other

Living Arrangements:

Lives with spouse Lives with parents Lives with child Lives alone Lives in care facility Lives with spouse & children Lives with domestic partner Lives with roommate Other

Smoking Status	Never smoker (<100 cigs equiv) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Current every day smoker Unknown if ever smoked Other	Type:	None Cigaretts Chewing Tobacco Other	How Long:
Alcohol:	No Yes Occasionally Socially Other	Type:	None Beer Wine Hard Liquor Other	How Long:
Illegal Drugs:	No Yes Other	Type:		How Long:
STD:	None Gonorrhea Syphilis Hepatitis HIV TB Other

Review of Systems

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GENERAL: Fever, weight loss, weight gain, fatigue?	None Fever Weight loss Weight gain Fatigue Other
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat	None Allergies Sinus Problems Chronic Cough Dry Throat / Mouth Hard of Hearing Other
CARDIOVASCULAR: High BP, Heart Disease, Vascular Disease	None HBP Heart Disease Vascular Disease Other
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD	None Asthma Bronchitis Emphysema COPD Other
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence	None painful urination frequent urination impotence yellow jaundice Other
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury	None joint pain stiffness swelling cramps arthritis Other
SKIN: growths, rashes, eczema, rosacea	None growths rash eczema rosacea Other
NEUROLOGICAL: Headaches, migraines, seizures	None numbness, paralysis headache seizures migraines Other
PSYCHIATRIC: Depression, Anxiety, Insomnia	None anxiety depression insomnia Other
ENDORCRINE: Thyroid, Diabetes	None diabetes hypothyroid hyperthoyroid Other
BLOOD/LYMPH: Anemia, hypercholesterolemia, bleeding problems	None anemia bleeding problems hypercholesterolemia Other
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus	None seasonal allergies rheumatoid lupus Other
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux	None Diarrhea Constipation Ulcer Acid Reflux Other

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