New Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Primary Doctor Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Primary

Insurance Information
Insurance Name:
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:
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:
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:

Adult Questionnaire


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

PRIMARY CARE PHYSICIAN: Last Visit Reason For Visit:

PATIENT MEDICAL HISTORY: HAs, Arthritis, Asthma, Diabetes, HBP, Heart, Infl. Bowel Dz, Seizures, Thyroid

Pregnant Or Nursing Recent Tetanus Shot Headaches
Notes

Injuries, Surgeries, Hospitalization

SYSTEMIC MEDS
Drug Allergies: Over The Counter Meds Vitamins

FAMILY MEDICAL HISTORY: Diabetes, HBP, Heart Dz, Cancer, Athritis, Lupus, Kidney, Thyroid, Other

Occupation: Hobbies:

Tobacco Type How Long
Alcohol Type How Long
Illegal Drugs Type How Long
STD
Personal Notes


REVIEW OF SYSTEMS

Do you currently have any of these problems?

GENERAL: Fever, weight loss, weight gain, fatigue?
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
ENDORCRINE: Thyroid, Diabetes
PSYCHIATRIC: Depression, Anxiety, Insomnia
NEUROLOGICAL: Headaches, migraines, seizures
SKIN: growths, rashes, acne
MUSCLES, BONES, JOINTS: Athritis, Joint Pains, Head or Neck Injury
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

Child Questionnaire


PARENT/PATIENT IMPRESSION

Study Habits:
Self-Esteem:
Cooperation:
Sports/Coordination
School/Work Productivity:


AREAS OF WEAKNESS

Signs of Eye Teaming Problems:
Covers or closes one eye when reading or outside
Rubs Eyes
Complains of Eyestrain
Complains of Headaches
Complains of Double Vision
Complains of words moving on a page
Inattentive
Poor Reading Comprehension
Loses Place
Frequent bumping into objects; spills
Knocks things over off of tables or desks
Avoids reading or close work
Dizziness or nausea in the car
Dizziness or nausea with reading
Fill in wrong "bubbles" on computer graded tests
Tension, nervousness, frustration with close work
Bright light bothering eyes
Falls asleep with reading
Signs of Tracking Problems:
Poor reading comprehension
Short attention span
Re-reading of lines
Head/body movement with reading
Misalign or misplace numbers in columns
Fill in wrong "bubbles" on computer graded tests
Tension, nervousness, frustration with close work
Skips lines and words often
Inattentive with reading
Loses place often
Must use finger or guide to keep place
Slow word to word reading
Signs of Visual Processing Disorders:
Trouble learning left from right
Reverses letters and numbers
Mistakes words with similar beginnings
Can't recognize the same word repeated on a page
Confuses similar words
Trouble learning basic math concepts of size and magnitude
Misalign or misplace numbers in columns
Difficulty reading maps or detailed drawings
Poor reading comprehension
Trouble with spelling and sight vocabulary
Poor spacing when writing; writes uphill or downhill
Trouble copying from board to book
Erases excessively
Can respond orally but not in writing
Seems to know material but does poorly on written tests
History of being at least 6 months behind grade level in reading
Awkward posture or pencil grip when writing
Poor recall of visually presented material
Slow or word to word reading
Signs of Focusing Problems:
Complains of blurred vision
Complains of blurred vision when looking from far to near or vice versa
Complains of eyestrain
Complains of headaches
Rubs eyes
Inattentive
Poor reading comprehension
Is tired at the end of the day
Holds things very close
Avoids reading or close work
Tension, nervousness, frustration with close work
Bright light bothering eyes
Falls asleep with reading












































AREAS OF IMPROVEMENT

Reading:
Improved reading
Increased interest in reading
Improved reading comprehension
Reading for longer periods
Reading on his/her own
Less loss of place while reading
Smoother oral reading
Reads for fun
Words on a page don't move around or run together
Less sleepiness when reading
Work:
Better quality work
Improved handwriting
Fewer problems with work
Complete work faster
Better spelling
Enjoying work more
Easier time working
Fewer letter reversals
Localization Navigation:
Improvement in sports
Less clumsy
Easier driving
Better at video games
Less dizziness or nausea with near work
Emotional Behavioral:
Improved self confidence
Improved or more positive attitude
Improved self-esteem
Improved concetration
Reduced frustration
Happier
Improved attention span
Better memory
Improved behavior at home/work
More relaxed
Improved family relations
Doesn't "fidget" as much
Less tired or fatigued
More outgoing
Maintains eye contact
Ocular Symptoms:
Fewer headaches
Better control of eyes
Improved distance vision
Reduced blur at near
Reduced or no double vision
Reduced strain/hurting of eyes
Improved depth perception
Improved vision in lazy eye
Less dependence on glasses
Eyes no longer water or tear
Better peripheral

Comments:

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