New Patient Form

Demographics

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

Address: City: State/ZipCode AL AK AZ AR CA CO CT DE DC FL GA HI 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 ID

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. Laura, Fischer Misc/Guardian

Billing Information

Is The Billing Address the Same?

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

Address

City	State	ZipCode
	AL AK AZ AR CA CO CT DE DC FL GA HI 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 ID

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None AARP Health Care Options/United HealthCare Claim Division AARP Medicare Complete Aetna Health Plan Allegiance Benefit Plan Management Allied Benefit Systems AmeriBen Anthem Blue Shield - California Asuris CBA Incorporated Cigna Healthcare Community Health Plan of Washington Coordinated Care Delta Health Systems EBMS Eyemed Vision Care First Choice Health Greenstone Health Care Plans Group Health Humana Claims Department Insurance Management Administrators Inc. Kaiser Permanente Claims Administration Lifewise of WA March Vision Care Medicaid Medicare Moda Health Molina Healthcare of Washington Monaco Vision Mutual of Omaha (United World Life Insurance CO) Northwest Administrators, INC Northwest Plumbers and Pipefitters Trust OptiCare Managed Vision Pacific Source Health Plans Palmetto GBA Railroad Medicare Premera Blue Shield Private Pay Providence Health Plan Secure Horizons Sentinel Security Life Shasta State Farm Health Insurance Sterling Connect 1 Sterling Option 1 Sterlinlg Insurance Operations Tricare West Region Claims Department Trusteed Plans Service Corporation UFCW Health & Welfare Trust UMR United Healthcare Vision Service Plan Web TPA
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 AARP Health Care Options/United HealthCare Claim Division AARP Medicare Complete Aetna Health Plan Allegiance Benefit Plan Management Allied Benefit Systems AmeriBen Anthem Blue Shield - California Asuris CBA Incorporated Cigna Healthcare Community Health Plan of Washington Coordinated Care Delta Health Systems EBMS Eyemed Vision Care First Choice Health Greenstone Health Care Plans Group Health Humana Claims Department Insurance Management Administrators Inc. Kaiser Permanente Claims Administration Lifewise of WA March Vision Care Medicaid Medicare Moda Health Molina Healthcare of Washington Monaco Vision Mutual of Omaha (United World Life Insurance CO) Northwest Administrators, INC Northwest Plumbers and Pipefitters Trust OptiCare Managed Vision Pacific Source Health Plans Palmetto GBA Railroad Medicare Premera Blue Shield Private Pay Providence Health Plan Secure Horizons Sentinel Security Life Shasta State Farm Health Insurance Sterling Connect 1 Sterling Option 1 Sterlinlg Insurance Operations Tricare West Region Claims Department Trusteed Plans Service Corporation UFCW Health & Welfare Trust UMR United Healthcare Vision Service Plan Web TPA
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 AARP Health Care Options/United HealthCare Claim Division AARP Medicare Complete Aetna Health Plan Allegiance Benefit Plan Management Allied Benefit Systems AmeriBen Anthem Blue Shield - California Asuris CBA Incorporated Cigna Healthcare Community Health Plan of Washington Coordinated Care Delta Health Systems EBMS Eyemed Vision Care First Choice Health Greenstone Health Care Plans Group Health Humana Claims Department Insurance Management Administrators Inc. Kaiser Permanente Claims Administration Lifewise of WA March Vision Care Medicaid Medicare Moda Health Molina Healthcare of Washington Monaco Vision Mutual of Omaha (United World Life Insurance CO) Northwest Administrators, INC Northwest Plumbers and Pipefitters Trust OptiCare Managed Vision Pacific Source Health Plans Palmetto GBA Railroad Medicare Premera Blue Shield Private Pay Providence Health Plan Secure Horizons Sentinel Security Life Shasta State Farm Health Insurance Sterling Connect 1 Sterling Option 1 Sterlinlg Insurance Operations Tricare West Region Claims Department Trusteed Plans Service Corporation UFCW Health & Welfare Trust UMR United Healthcare Vision Service Plan Web TPA
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:

Chief Complain and Ocular History

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CHIEF COMPLAINT
SECONDARY COMPLAINTS:

OCULAR HISTORY

Last Eye Exam:

1 year 2 years 3 years First Exam Never 4 years 5 years 6 years 7 years 8 years 9 years 10 years Other

Doctor/Office:

Doesn't Remember Never Dr. Ulrich Dr. Garn Dr. Schnibbe, OD Dr. Olsen Other

Eye surgery:	No Cataracts removed LASIK Eye lid Retinal laser Strabismus Other	Eye injury:	No metal rust ring abrasion cut Other	Eye infection:	No Pink eye Corneal Ulcer Other	Headaches	No Yes Migraines Worse w/nearwork HA/Migraines HAs Occasianal HAs Other
Eyestrain	No Yes with near work with distance work at computer Tired Other	Eye Pain	No Yes Other	Glaucoma	No Yes Other	Cataracts	No Yes Start of cat Mild Removed IOL Other
Macular Deg.	No Yes Other	Retinal detach	No Yes Other	Lazy Eye	No Right eye Left eye Other	Eyelid droop	No Yes Other
Diplopia	No Diplopia horizontal In one eye intermittent occasional only if tired rare side by side vertical Other	Itch	No Yes Seasonal Allergies Sometimes Occasional In past Other	Burn	No Yes In past Occasional Other	Tear	No Yes In past Occasional Other
Discharge	No Clear Green In past Morning Occasional Previously Stringy Yellow Yes Other	FBS	No Yes Sandy gritty feeling scratchy Dry sometimes occasionally Other	Redness	No Yes In past Occasional Other	Lid edema	No Yes Other
Floaters	No Yes longstanding/no change Yes stable, longstanding Other	Flashes	No Yes Other	Glare	No Yes Headlights Driving at night Sunlight Other	Photo	No Yes sunlight bother headlights bother Photophobia sensitive to bright lights Other
Dry:	No Yes Occasionally Other	GL	Yes No Never In the past Occasionally Driving OTC Readers Reading Only FTW Sometimes Wear as needed Wear for TV Lost Broken At home Other	CL	No Yes In the past Never Other

Notes:

FAMILY HISTORY

Cataracts:	No Aunt Brother Dad Daughter Father Grandfather Grandmother Grandparents Mom Mother Parent Siblings Sister Son Uncle Unknown Yes Other	Macular Degen:	No Aunt Brother Dad Daughter Father Grandfather Grandmother Grandparents Mom Mother Parent Siblings Sister Son Uncle Unknown Yes Other	Crossed / Lazy:	No Aunt Brother Dad Daughter Father Grandfather Grandmother Grandparents Mom Mother Parent Siblings Sister Son Uncle Unknown Yes Other
Retinal Detach/Disease:	No Aunt Brother Dad Daughter Father Grandfather Grandmother Grandparents Mom Mother Parent Siblings Sister Son Uncle Unknown Yes Other	Glaucoma:	No Aunt Brother Dad Daughter Father Grandfather Grandmother Grandparents Mom Mother Parent Siblings Sister Son Uncle Unknown Yes Other	Blindness/Other:	No Aunt Brother Dad Daughter Father Grandfather Grandmother Grandparents Mom Mother Parent Siblings Sister Son Uncle Unknown Yes Other

NOTES:

Medical History

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CURRENT MEDICAL HISTORY

DM:	NO YES Type 2 DM Type 1 DM Gestational Diabetes Other	Heart Disease:	NO YES In past Other	Hypertension:	NO YES BORDERLINE BEING TESTED In past Med Control Medication controlled Monitoring Other	Stroke:	NO YES Other
Cancer:	No Yes In past Breast Prostate Lung Other	Arthritis:	NO YES In past Rheumatoid Other	Other:	NO Thyroid Lupus Cholesterol Other

Injuries, Surgeries, Hospitalization:

Pregnant / Nursing:	No Yes Unsure Pregnant Nursing Other
Primary Care Provider:	Dr. David Fischer, MD Dr. Greg Doering Dr. Marla Struebin Other	Last Visit:	1 week 1 month 3 months 6 months 1 year 2 years Other

Systemic Medications:	None Acetaminophen Actos Acyclovir Adderall Advil Albuterol Allegra Altase Amaryl Amiodarone Amoxycillin ASA 81mg Aspirin Atenolol Augmentin Baby Aspirin Bactroban Benadryl Birth Control Buspar Calcium Captopril Carbamazepine Cefzil Celebrex Celexa Cetirizine Cipro Clonidin Coumadin Cozar Crestor Cymbalta Depakote Detrol Diclofenac Dilantin Diovan Effexor Flexeril Flomax Flonase Fluoride Furosamide Glipizide Glucophage Glyburide HCTZ Humalog Humulin Hydrocodone Hydrocortisone Ibuprofen Iron Lantus Lasix Levaquin Levothyroxine Lexapro Lipitor Lisinopril Loratadine Lortab Medrol Metformin Methlyprednisolone Microzide Mobic MS Contin Multivitamin Naproxen Nasacort Neurontin Novalog Omeprazole Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Prilosec Protonix Proventil Prozac Ritalin Seraquel Singulair Singular Synthroid Tetracycline Topamax Tramadol Trazadone Tylenol Valium Vicodin Vitamin Wellbutrin Xanax Zantac Zestril Zocor Zoloft Zyrtec None Other		Acetaminophen Actos Acyclovir Adderall Advil Albuterol Allegra Altase Amaryl Amiodarone Amoxycillin ASA 81mg Aspirin Atenolol Augmentin Baby Aspirin Bactroban Benadryl Birth Control Buspar Calcium Captopril Carbamazepine Cefzil Celebrex Celexa Cetirizine Cipro Clonidin Coumadin Cozar Crestor Cymbalta Depakote Detrol Diclofenac Dilantin Diovan Effexor Flexeril Flomax Flonase Fluoride Furosamide Glipizide Glucophage Glyburide HCTZ Humalog Humulin Hydrocodone Hydrocortisone Ibuprofen Iron Lantus Lasix Levaquin Levothyroxine Lexapro Lipitor Lisinopril Loratadine Lortab Medrol Metformin Methlyprednisolone Microzide Mobic MS Contin Multivitamin Naproxen Nasacort Neurontin None Novalog Omeprazole Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Prilosec Protonix Proventil Prozac Ritalin Seraquel Singulair Singular Synthroid Tetracycline Topamax Tramadol Trazadone Tylenol Valium Vicodin Vitamin Wellbutrin Xanax Zantac Zestril Zocor Zoloft Zyrtec Other		Acetaminophen Actos Acyclovir Adderall Advil Albuterol Allegra Altase Amaryl Amiodarone Amoxycillin ASA 81mg Aspirin Atenolol Augmentin Baby Aspirin Bactroban Benadryl Birth Control Buspar Calcium Captopril Carbamazepine Cefzil Celebrex Celexa Cetirizine Cipro Clonidin Coumadin Cozar Crestor Cymbalta Depakote Detrol Diclofenac Dilantin Diovan Effexor Flexeril Flomax Flonase Fluoride Furosamide Glipizide Glucophage Glyburide HCTZ Humalog Humulin Hydrocodone Hydrocortisone Ibuprofen Iron Lantus Lasix Levaquin Levothyroxine Lexapro Lipitor Lisinopril Loratadine Lortab Medrol Metformin Methlyprednisolone Microzide Mobic MS Contin Multivitamin Naproxen Nasacort Neurontin None Novalog Omeprazole Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Prilosec Protonix Proventil Prozac Ritalin Seraquel Singulair Singular Synthroid Tetracycline Topamax Tramadol Trazadone Tylenol Valium Vicodin Vitamin Wellbutrin Xanax Zantac Zestril Zocor Zoloft Zyrtec Other		Acetaminophen Actos Acyclovir Adderall Advil Albuterol Allegra Altase Amaryl Amiodarone Amoxycillin ASA 81mg Aspirin Atenolol Augmentin Baby Aspirin Bactroban Benadryl Birth Control Buspar Calcium Captopril Carbamazepine Cefzil Celebrex Celexa Cetirizine Cipro Clonidin Coumadin Cozar Crestor Cymbalta Depakote Detrol Diclofenac Dilantin Diovan Effexor Flexeril Flomax Flonase Fluoride Furosamide Glipizide Glucophage Glyburide HCTZ Humalog Humulin Hydrocodone Hydrocortisone Ibuprofen Iron Lantus Lasix Levaquin Levothyroxine Lexapro Lipitor Lisinopril Loratadine Lortab Medrol Metformin Methlyprednisolone Microzide Mobic MS Contin Multivitamin Naproxen Nasacort Neurontin None Novalog Omeprazole Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Prilosec Protonix Proventil Prozac Ritalin Seraquel Singulair Singular Synthroid Tetracycline Topamax Tramadol Trazadone Tylenol Valium Vicodin Vitamin Wellbutrin Xanax Zantac Zestril Zocor Zoloft Zyrtec Other
	Acetaminophen Actos Acyclovir Adderall Advil Albuterol Allegra Altase Amaryl Amiodarone Amoxycillin ASA 81mg Aspirin Atenolol Augmentin Baby Aspirin Bactroban Benadryl Birth Control Buspar Calcium Captopril Carbamazepine Cefzil Celebrex Celexa Cetirizine Cipro Clonidin Coumadin Cozar Crestor Cymbalta Depakote Detrol Diclofenac Dilantin Diovan Effexor Flexeril Flomax Flonase Fluoride Furosamide Glipizide Glucophage Glyburide HCTZ Humalog Humulin Hydrocodone Hydrocortisone Ibuprofen Iron Lantus Lasix Levaquin Levothyroxine Lexapro Lipitor Lisinopril Loratadine Lortab Medrol Metformin Methlyprednisolone Microzide Mobic MS Contin Multivitamin Naproxen Nasacort Neurontin None Novalog Omeprazole Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Prilosec Protonix Proventil Prozac Ritalin Seraquel Singulair Singular Synthroid Tetracycline Topamax Tramadol Trazadone Tylenol Valium Vicodin Vitamin Wellbutrin Xanax Zantac Zestril Zocor Zoloft Zyrtec Other		Acetaminophen Actos Acyclovir Adderall Advil Albuterol Allegra Altase Amaryl Amiodarone Amoxycillin ASA 81mg Aspirin Atenolol Augmentin Baby Aspirin Bactroban Benadryl Birth Control Buspar Calcium Captopril Carbamazepine Cefzil Celebrex Celexa Cetirizine Cipro Clonidin Coumadin Cozar Crestor Cymbalta Depakote Detrol Diclofenac Dilantin Diovan Effexor Flexeril Flomax Flonase Fluoride Furosamide Glipizide Glucophage Glyburide HCTZ Humalog Humulin Hydrocodone Hydrocortisone Ibuprofen Iron Lantus Lasix Levaquin Levothyroxine Lexapro Lipitor Lisinopril Loratadine Lortab Medrol Metformin Methlyprednisolone Microzide Mobic MS Contin Multivitamin Naproxen Nasacort Neurontin None Novalog Omeprazole Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Prilosec Protonix Proventil Prozac Ritalin Seraquel Singulair Singular Synthroid Tetracycline Topamax Tramadol Trazadone Tylenol Valium Vicodin Vitamin Wellbutrin Xanax Zantac Zestril Zocor Zoloft Zyrtec Other		Acetaminophen Actos Acyclovir Adderall Advil Albuterol Allegra Altase Amaryl Amiodarone Amoxycillin ASA 81mg Aspirin Atenolol Augmentin Baby Aspirin Bactroban Benadryl Birth Control Buspar Calcium Captopril Carbamazepine Cefzil Celebrex Celexa Cetirizine Cipro Clonidin Coumadin Cozar Crestor Cymbalta Depakote Detrol Diclofenac Dilantin Diovan Effexor Flexeril Flomax Flonase Fluoride Furosamide Glipizide Glucophage Glyburide HCTZ Humalog Humulin Hydrocodone Hydrocortisone Ibuprofen Iron Lantus Lasix Levaquin Levothyroxine Lexapro Lipitor Lisinopril Loratadine Lortab Medrol Metformin Methlyprednisolone Microzide Mobic MS Contin Multivitamin Naproxen Nasacort Neurontin None Novalog Omeprazole Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Prilosec Protonix Proventil Prozac Ritalin Seraquel Singulair Singular Synthroid Tetracycline Topamax Tramadol Trazadone Tylenol Valium Vicodin Vitamin Wellbutrin Xanax Zantac Zestril Zocor Zoloft Zyrtec Other		Acetaminophen Actos Acyclovir Adderall Advil Albuterol Allegra Altase Amaryl Amiodarone Amoxycillin ASA 81mg Aspirin Atenolol Augmentin Baby Aspirin Bactroban Benadryl Birth Control Buspar Calcium Captopril Carbamazepine Cefzil Celebrex Celexa Cetirizine Cipro Clonidin Coumadin Cozar Crestor Cymbalta Depakote Detrol Diclofenac Dilantin Diovan Effexor Flexeril Flomax Flonase Fluoride Furosamide Glipizide Glucophage Glyburide HCTZ Humalog Humulin Hydrocodone Hydrocortisone Ibuprofen Iron Lantus Lasix Levaquin Levothyroxine Lexapro Lipitor Lisinopril Loratadine Lortab Medrol Metformin Methlyprednisolone Microzide Mobic MS Contin Multivitamin Naproxen Nasacort Neurontin None Novalog Omeprazole Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Prilosec Protonix Proventil Prozac Ritalin Seraquel Singulair Singular Synthroid Tetracycline Topamax Tramadol Trazadone Tylenol Valium Vicodin Vitamin Wellbutrin Xanax Zantac Zestril Zocor Zoloft Zyrtec Other
	Acetaminophen Actos Acyclovir Adderall Advil Albuterol Allegra Altase Amaryl Amiodarone Amoxycillin ASA 81mg Aspirin Atenolol Augmentin Baby Aspirin Bactroban Benadryl Birth Control Buspar Calcium Captopril Carbamazepine Cefzil Celebrex Celexa Cetirizine Cipro Clonidin Coumadin Cozar Crestor Cymbalta Depakote Detrol Diclofenac Dilantin Diovan Effexor Flexeril Flomax Flonase Fluoride Furosamide Glipizide Glucophage Glyburide HCTZ Humalog Humulin Hydrocodone Hydrocortisone Ibuprofen Iron Lantus Lasix Levaquin Levothyroxine Lexapro Lipitor Lisinopril Loratadine Lortab Medrol Metformin Methlyprednisolone Microzide Mobic MS Contin Multivitamin Naproxen Nasacort Neurontin None Novalog Omeprazole Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Prilosec Protonix Proventil Prozac Ritalin Seraquel Singulair Singular Synthroid Tetracycline Topamax Tramadol Trazadone Tylenol Valium Vicodin Vitamin Wellbutrin Xanax Zantac Zestril Zocor Zoloft Zyrtec Other		Acetaminophen Actos Acyclovir Adderall Advil Albuterol Allegra Altase Amaryl Amiodarone Amoxycillin ASA 81mg Aspirin Atenolol Augmentin Baby Aspirin Bactroban Benadryl Birth Control Buspar Calcium Captopril Carbamazepine Cefzil Celebrex Celexa Cetirizine Cipro Clonidin Coumadin Cozar Crestor Cymbalta Depakote Detrol Diclofenac Dilantin Diovan Effexor Flexeril Flomax Flonase Fluoride Furosamide Glipizide Glucophage Glyburide HCTZ Humalog Humulin Hydrocodone Hydrocortisone Ibuprofen Iron Lantus Lasix Levaquin Levothyroxine Lexapro Lipitor Lisinopril Loratadine Lortab Medrol Metformin Methlyprednisolone Microzide Mobic MS Contin Multivitamin Naproxen Nasacort Neurontin None Novalog Omeprazole Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Prilosec Protonix Proventil Prozac Ritalin Seraquel Singulair Singular Synthroid Tetracycline Topamax Tramadol Trazadone Tylenol Valium Vicodin Vitamin Wellbutrin Xanax Zantac Zestril Zocor Zoloft Zyrtec Other		Acetaminophen Actos Acyclovir Adderall Advil Albuterol Allegra Altase Amaryl Amiodarone Amoxycillin ASA 81mg Aspirin Atenolol Augmentin Baby Aspirin Bactroban Benadryl Birth Control Buspar Calcium Captopril Carbamazepine Cefzil Celebrex Celexa Cetirizine Cipro Clonidin Coumadin Cozar Crestor Cymbalta Depakote Detrol Diclofenac Dilantin Diovan Effexor Flexeril Flomax Flonase Fluoride Furosamide Glipizide Glucophage Glyburide HCTZ Humalog Humulin Hydrocodone Hydrocortisone Ibuprofen Iron Lantus Lasix Levaquin Levothyroxine Lexapro Lipitor Lisinopril Loratadine Lortab Medrol Metformin Methlyprednisolone Microzide Mobic MS Contin Multivitamin Naproxen Nasacort Neurontin None Novalog Omeprazole Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Prilosec Protonix Proventil Prozac Ritalin Seraquel Singulair Singular Synthroid Tetracycline Topamax Tramadol Trazadone Tylenol Valium Vicodin Vitamin Wellbutrin Xanax Zantac Zestril Zocor Zoloft Zyrtec Other		Acetaminophen Actos Acyclovir Adderall Advil Albuterol Allegra Altase Amaryl Amiodarone Amoxycillin ASA 81mg Aspirin Atenolol Augmentin Baby Aspirin Bactroban Benadryl Birth Control Buspar Calcium Captopril Carbamazepine Cefzil Celebrex Celexa Cetirizine Cipro Clonidin Coumadin Cozar Crestor Cymbalta Depakote Detrol Diclofenac Dilantin Diovan Effexor Flexeril Flomax Flonase Fluoride Furosamide Glipizide Glucophage Glyburide HCTZ Humalog Humulin Hydrocodone Hydrocortisone Ibuprofen Iron Lantus Lasix Levaquin Levothyroxine Lexapro Lipitor Lisinopril Loratadine Lortab Medrol Metformin Methlyprednisolone Microzide Mobic MS Contin Multivitamin Naproxen Nasacort Neurontin None Novalog Omeprazole Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Prilosec Protonix Proventil Prozac Ritalin Seraquel Singulair Singular Synthroid Tetracycline Topamax Tramadol Trazadone Tylenol Valium Vicodin Vitamin Wellbutrin Xanax Zantac Zestril Zocor Zoloft Zyrtec Other

Drug Allergies:
Eye drops:	None Soothe Visine Thera Tears Thera Tears Preservative Free Thera Tears gel Clear Eyes Systane Blink Generic artificial tears Refresh Genteal Gel Restasis Other
Notes:

FAMILY MEDICAL HISTORY: Arthritis, Cancer, Diabetes, Heart Dz, HTN, Kidney Dz, Lupus, Thyroid, Other

SOCIAL HISTORY

Occupation:

Student Retired Teacher Engineer Truck Driver 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

School / Grade:

10th 11th 12th 1st 2nd 3rd 4th 5th 6th 7th 8th 9th College Freshman Graduate School Headstart Junior Kindergarten Pre-K Preschool Senior Sophmore Other

Tobacco:	No Yes In Past Rarely Occasionally Socially Other	Type:	None Cigarettes Chewing Tobacco Cigars Smokeless Snuff Former Smoker Other	How Long:	5 years 10 Year 15 years 20 Years 25 Years 30 Years 35 Years 40 Years Other	How much:	1/2 pack / day 1 pack / day 1 Can/day 2 pack/day Daily Other
Alcohol:	No Yes Occasionally Socially Rarely In past Other	Type:	None All Types Beer Hard Liquor Mixed Drinks Wine Other	How Long:	5 years 10 Year 15 years 20 Years 25 Years 30 Years 35 Years 40 Years Other	How much:	Occasional Sometimes Few Rare Socially Other
Illegal Drugs:	No Yes Past Other	Type:	None Other	How Long:	10 Year 15 years 20 Years 5 years Other

STD (Gonorrhea, Hepatitis, HIV, Syphilis):

Notes:

Review of Systems

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CONSTITUTIONAL: Cancer, Fever, weight loss, weight gain, fatigue	NO Negative Developmental Disorders Cancer Chronic Fatigue Syndrome Other
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat	NO Allergies/Hay Fever Sinus Congestion Allergies Runny Nose Post Nasal Drip Chronic Cough Dry Throat / Mouth Seasonal allergies Sinus Problems Hay Fever Allergies/Hayfever, Sinus Congestion, Runny Nose, Post Nasal Drip, Hearing Impaired Laryngitis Sinusitis Dry Mouth Other
CARDIOVASCULAR: HTN, Heart Surgery, Vascular Disease	NO HTN Surgery Vascular Disease Stroke MitroValve Prolapse Heart Arrythmia Heart Attack Heart Disease Heart Problems Other
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD	NO Asthma Bronchitis Chronic Bronchitis Emphysema COPD Sleep Apnea Other
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence	NO frequent urination impotence yellow jaundice Surgery UTI Prostate problems Kidney problems Kidney Transplant Kidney Stones STD - Herpetic/Chlamydia Prostate Disease/Cancer Other
MUSCLES, BONES, JOINTS: Athritis, Joint Pains, Head or Neck Injury	NO arthritis Rheumatoid Arthritis Muscle Pain / Joint Pain Muscle Pain joint pain stiffness swelling cramps Broken bones Fractures Back problems Neck Problems Fibromyalgia Other
SKIN: growths, rashes, acne	NO Acne Eczema Itchy skin psoriasis Rosacea Other
NEUROLOGICAL: Headaches, migraines, seizures	NO Headaches Headaches / Migraines Tremors Paralysis Migraines Migraines with visual aura Brain Trauma concussion Brain Tumor Seizures Other
PSYCHIATRIC: Depression, Anxiety, Insomnia	NO anxiety depression insomnia Mood Disorder Bipolar Manic Depression Alzheimer's Panic Attacks Psychiatric issues Attention Deficit PTSD Autism Other
ENDORCRINE: Thyroid, Diabetes	NO Diabetes Grave's Disease hyperthoyroid hypothyroid Thyroid Problems Type 1 Diabetes Type 2 Diabetes Other
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems	NO bleeding cholestrolemia anemia Bleeding Problems Other
ALLERGIC / IMMUNOLOGIC: Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus	NO hives Sarcoid Lupus Rheumatoid Arthritis Environmental Allergies Multiple Sclerosis Sjogrens Syndrome HIV Other
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux	NO Acid Reflux Chron's Disease Chronic Constipation Chronic Diarrhea Constipation Diarrhea Heart Burn None Ulcer Irritable Bowel Syndrome IBS Other

OTHER:

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