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 Douglas Leo, O.D. William Wong, O.D. Richard Gray, O.D. Walk In 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:

Vision 1

Insurance Information

Insurance Name:	None 3M Safety AETNAHMO AETNAPPO AMPHASTAR ANTHEMBC ANTHEMPO CIGNA CSF CSI DISCOUNT EYEMED FPD FUSD HUMANA KAISER LLURISK MEDI-CAL MEDICARE MES NESTLE NVA REGAL SAFEGUARD Southern California Lumber Trust SPECTERA SUPERIOR TLC TRICARE UFCWU VSP
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:

Vision 2

Insurance Information

Insurance Name:	None 3M Safety AETNAHMO AETNAPPO AMPHASTAR ANTHEMBC ANTHEMPO CIGNA CSF CSI DISCOUNT EYEMED FPD FUSD HUMANA KAISER LLURISK MEDI-CAL MEDICARE MES NESTLE NVA REGAL SAFEGUARD Southern California Lumber Trust SPECTERA SUPERIOR TLC TRICARE UFCWU VSP
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:

Primary Medical

Insurance Information

Insurance Name:	None 3M Safety AETNAHMO AETNAPPO AMPHASTAR ANTHEMBC ANTHEMPO CIGNA CSF CSI DISCOUNT EYEMED FPD FUSD HUMANA KAISER LLURISK MEDI-CAL MEDICARE MES NESTLE NVA REGAL SAFEGUARD Southern California Lumber Trust SPECTERA SUPERIOR TLC TRICARE UFCWU VSP
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:

Chief Complaints

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

Chief Complaints

Reason for Visit
Secondary Complaints:
	Spanish Speaking?

Review of Ocular System

Injuries, Infections, Surgeries, Diseases

Last Eye Exam:

1 year 2 years 3 years Other

Doctor:

Wal-Mart Exam 2000 Private Other

Family Ocular History

Glaucoma:	No father Grandparent mother Parents Sibling Other	Cataracts:	No father Grandparent mother Parents Siblings Other	Macular Degeneration:	No Parents Siblings Grandparent Other
Retinal Detachment:	No Parents Siblings Grandparent Other	Crossed / Lazy Eye:	No Parents Siblings Grandparent Other

Previous Vision Correction

Primary Vision Correction:	None Glasses Contacts - Soft Contacts - Gas Perm PMMA Other	Type of CLs worn in past:	None Soft Disposable Soft - Multifocal Soft Conventional RGP Other	Cleaner:	Aquify Pure Moist BioTrue Boston ClearCare Optifree Renu Generic Unknown Other
Disposal:	2 weeks Monthly Dailies Other

NOTES:

Medical History

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

Medical History

Patient Medical History:	Arthritis Asthma Cancer Cancer breast Cholesterol D.M. type I D.M. type II Denies any medical history Diagnosed As HIV+ Headaches Heart Condition HTN HX Of Drug/Alcohol Abuse Lupus MS multiple sclerosis Osteoporosis Seizure Disorder Thyroid Disease Other
Injuries, Surgeries, Hospitalization:
Pregnant Or Nursing:	No Yes Unsure Other

Primary Care Physcian:

None Other

Last Visit:

< 6 Months < 1 Year 1-2 Years > 2 Years Other

Diabetes Diabetic Retin Hypertension Glaucoma ARMD Arcus

Systemic Medications:	None Albuterol/Ventolin Amlodipine/Norvasc Amoxicillin Atenolol/Tenormin Atorvastatin/Lipitor Bonivia/Ibandronate Bupropion/Wellbutrin Calcium Cancer Meds Claritin/Loratidine Cymbalta D.M. Pills Flonase Heart Meds HTN Meds Indomethacin/Indocin Insulin Levothroid Lexapro Metformin/Glucophage Motrin/Iburofen Nexium Pepcid/Famotidine Plaquenil Plavix Restasis/Cyclosporine Thyroid Meds Zyrtec/Cetirizine Other	None HTN Meds D.M. Pills Insulin Heart Meds Thyroid Meds Cancer Meds Other	None HTN Meds D.M. Pills Insulin Heart Meds Thyroid Meds Cancer Meds Other
	None HTN Meds D.M. Pills Insulin Heart Meds Thyroid Meds Cancer Meds Other	None HTN Meds D.M. Pills Insulin Heart Meds Thyroid Meds Cancer Meds Other	None HTN Meds D.M. Pills Insulin Heart Meds Thyroid Meds Cancer Meds Other

Glaucoma Medications:	None Timoptic Xalatan Pilo-carpine Other	Eye Medications:	None Anti-biotic Steroid Wetting drops Allergy drops Other	Drug Allergies:	NKDA Codeine Penicillin Sulfa Other
Over The Counter Medications:	Acetomenophin Asprin Ibuprofen None Visine Other	Vitamins:	None General OTC I-Caps Ocuvite Other

Family Medical History

None Adopted Athritis Cancer Cardiovascular Disease Diabetes HTN Kidney Disease Lupus None Thyroid Cholesteral Other	None Adopted Athritis Cancer Cardiovascular Disease Diabetes HTN Kidney Disease Lupus Thyroid Other	None Adopted Athritis Cancer Cardiovascular Disease Diabetes HTN Kidney Disease Lupus Thyroid Other
None Adopted Athritis Cancer Cardiovascular Disease Diabetes HTN Kidney Disease Lupus Thyroid Other	None Adopted Athritis Cancer Cardiovascular Disease Diabetes HTN Kidney Disease Lupus Thyroid Other	None Adopted Athritis Cancer Cardiovascular Disease Diabetes HTN Kidney Disease Lupus Thyroid Other

Social History

Occupation:

Hobbies:

Tobacco:	No Yes 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

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

GENERAL: Fever, weight loss, weight gain, fatigue?	Denies New general health changes Other
EAR, NOSE, THROAT: Allergies, Sinus, Cough	Denies New E.N.T. problems Other
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease	Denies New cardiovascular problems Other
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD	Denies New respiratory problems Other
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence	Denies New problems Other
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury	Denies New problems Other
SKIN: growths, rashes, acne	Denies New problems Other
NEUROLOGICAL: Headaches, migraines, seizures	Denies New problems Other
PSYCHIATRIC: Depression, Anxiety, Insomnia	Denies New problems Other
ENDORCRINE: Thyroid, Diabetes	Denies New problems Other
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems	Denies New problems Other
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux	Denies New problems Other
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS	Denies New problems Other

Submit Data