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 Primary Doctor No Doctor Assigned Dr. McGowan OD, Joseph Dr. Doan, OD, Yen Dr. Nguyen OD, Thi Dr. Novak, Michaela 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:

Medical History

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

Chief complaint

Occupation:

Employer:

Other eye issues or problems

I currently wear glasses:	Full-time	Part-time	If part-time, how often/when?	Occasionally Driving Reading / Computer After contact lens removal 1-2 times per week Half time Sports Weekends Social activities Other
I currently wear contacts:	Full-time	Part-time	If part-time, how often/when?	Occasionally Driving 1-2 times per week Half time Sports Weekends Social activities Other

Contact Lense Wearers: Are your lenses comfortable?     YesNo Soft Rigid Gas Permeable

What solution do you use?	Optifree Pure Moist None Optifree Replenish Optifree Express Renu Biotrue Clear Care Kirkland Signature Revitalens Generic store brand Boston Advance Boston original Optimum B & L Gas Perm Unique Ph Other	Current Brand:	Acuvue 1-day Acuvue 1-day Moist Acuvue 1-day Trueye Acuvue 2 Acuvue Oasys Acuvue Oasys for Astigmatism Acuvue Oasys for Presbyopia Acuvue Advance Acuvue Advance for Astigmatism Air Optix Air Optix Night & Day Air Optix For Astigmatism Air Optix Multifocal Avaira Biomedic Toric Biomedic XC Biofinity Biofinity Toric Biofinity Multifocal Clearsight 1 day Clearsight 1 day Toric Focus Dailies Standard Focus Dailies AC plus Focus Dailies Toric Frequency 55 Frequency 55 Toric Frequency 55 Aspheric Freshlook colorblends Proclear Proclear 1 day Proclear EP Proclear Multifocal Purevision Purevision 2 Purevision 2 Toric Purevision Multifocal Soflens 38 Soflens Toric Soflens Daily Disposable Soflens Multifocal Vertex Toric Boston EO Boston ES Boston XO Fluoroperm 60 Menicon Z Thin RGP - unknown material Other
What is your replacement schedule?	Daily Weekly Every 2 weeks Monthly If they feel bad Quarterly Yearly Other	How old is your current pair?	new 1-2 weeks 2-4 weeks very old Other
Mode:	Daily Extended Flex Other	Please list all eyedrops you use (OTC and Rx):	none Blink Genteal Optive Refresh Plus Similisan Systane Generic artificial tears Murine Visine Lumigan Travatan Xalatan Timoptic Other
How often used?:	daily occasionally rarely Other

Do you have a history of any of the following, or are you currently experiencing any of the following?

	YES	NO
Blindness
Eye Turn (Strabismus)
Lazy Eye (Amblyopia)
Keratoconus
Macular Degeneration
Retinal Detachment
Glaucoma
Cataracts

	YES	NO
Headaches
Blurred Vision
Double Vision
Eyes "hurt" or "tired"
Floaters
Flashing Lights
Eyes Feel Sandy/Gritty

	YES	NO
Halos Around Lights
Bothered By Light/Sun
Frequent Styes
Eyes Frequently Red
Eyes Itch
Eyes Burn
Eyes Tear
Eyes Feel Dry

List any eye surgeries:	none Other
Other eye disease or condition	none Other
Describe any eye injuries:	none Other

How many hours a day do you use a computer?

<2 hours 2 - 4 hours 5 - 8 hours 9 - 12 hours 12+ hours Other

Describe any visual symptoms from computer use:

none Eye strain Blurred vision Headache Dry eyes Watery Itch Burn Double vision Other

Do you have, or have ever had, any CHRONIC problems in the following areas?

	YES	NO
Migraines
Multiple Sclerosis
Diabetes
Thyroid Problems

	YES	NO
Arthritis
Allergies/Hay Fever
Asthma
Emphysema

	YES	NO
High Blood Pressure
Stroke
Anemia
Cancer

Notes:

FAMILY HISTORY        Family history is unknown/adopted

Any history of the following in any family members (parents, grandparents, siblings, children)?

	YES	-	NO	-	RELATIONSHIP TO PATIENT
Poor Vision					Mother Father Sister Brother Aunt Uncle Grandmother Grandfather Other
Blindness					Mother Father Sister Brother Aunt Uncle Grandmother Grandfather Other
Eye Turn (Strabismus)					Mother Father Sister Brother Aunt Uncle Grandmother Grandfather Other
Lazy Eye (Amblyopia)					Mother Father Sister Brother Aunt Uncle Grandmother Grandfather Other
Glaucoma					Mother Father Sister Brother Aunt Uncle Grandmother Grandfather Other
Cataracts					Mother Father Sister Brother Aunt Uncle Grandmother Grandfather Other
Macular Degeneration					Mother Father Sister Brother Aunt Uncle Grandmother Grandfather Other
Retinal Detachment/Disease					Mother Father Sister Brother Aunt Uncle Grandmother Grandfather Other

	YES	-	NO	-	RELATIONSHIP TO PATIENT
Cancer					Mother Father Sister Brother Aunt Uncle Grandmother Grandfather Other
Diabetes					Mother Father Sister Brother Aunt Uncle Grandmother Grandfather Other
High Blood Pressure					Mother Father Sister Brother Aunt Uncle Grandmother Grandfather Other
Stroke					Mother Father Sister Brother Aunt Uncle Grandmother Grandfather Other
Thyroid Disease					Mother Father Sister Brother Aunt Uncle Grandmother Grandfather Other
Other Inherited Disease					Mother Father Sister Brother Aunt Uncle Grandmother Grandfather Other
If yes, what disease?

MEDICAL HISTORY / REVIEW OF SYSTEMS:

Physician's Name:		Last Visit Date:
Physician's Address:		Physician's Phone Number:

Pharmacy Name:

Pharmacy Phone:

Pharmacy Address:

List all medications you are currently taking (including any OTC/vitamins):	Allergies/Alerts:

Race:

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

Ethnicity:

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

Preferred Language:

English Spanish Other

Are you pregnant or nursing?Yes No         If yes, what is the due/birth date?

How often do you smoke/use tobacco products?	Never Occasionally Daily Other
How often do you consume alcohol:	Never Occasionally Daily Other

Who referred you to our office?
If not referred, how did you hear about Tanglewood Vision Center?	Family member Insurance list Coworker Friend Primary Care Doctor Internet Drove by Other

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