New Patient Form

Demographics

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

Address: City: State/ZipCode 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 Dr. Ben, Popilsky Dr. Pretest, Pretest Misc/Guardian

Billing Information

Is The Billing Address the Same?

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

Address

City	State	ZipCode
	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:

Primary

Insurance Information

Insurance Name:	None --- (Ben~E~lect) A A R P A A R P AARP AARP DISC PLAN Adventist Risk Management Aetna AETNA Vision Allied Administrators Antham Anthem Anthem Blue Cross Anthem Blue Cross anthem.com/ca Anthem Blue View Vision anthem clue cross Anthem Freedom Blue Benefits & Risk Management Services Blue Sheild of CA Blue Cross Blue Cross Anthem Freedom Blue Plan Blue Cross Blue Shield Blue Cross Blue Shield` blue cross, blue shield Blue Cross/Blue Shield BLUE Sheild of CA Blue Shield Blue Shield HMO Blue Shield of CA Blue Shield of California Blue View Vision BlueShield brms.claims.com Cabrillo Discount Cabrillo employee discount Cabrillo Host Lions Club Cabrillo Host Lions Club of Aptos Carpenters Health & Welfare cigna Cigna - CISCO City of Sebastopol CLANCEY, MARGERY COASTAL TPA Davis Vision Davis Vision/ MEDICARE DSP EJS Insurance Electrical Workers Health Local 234 Eye Med EyeMed EYEMED ECPA EyeMed Vision Care EyeMed Vision Care Discount Plan EyeMed Vision Care (NO BILLING NEEDED) EyeMed Vision Care Access Discount Plan FEP Blue Bision Freedom Blue Guardian GWH-Cigna PPO Health Net HealthNet I pay Cash IBEW LOCAL 234 (PACIFIC HEALTH) Interplan Health/Health Markets Lion's Club voucher $300 Lions Club voucher Lions Club voucher (12/28/2011) Lyons Club medica MEDICAL EYE SERVICES MEDICARE MEDICARE (EyeMed) Disc Plan Scanned in Auth Medicare and Freedom Blue mutual ins. admin inc N/A n/a I Pay Cash na No insurance None none ;{ NVA Insurance on file On file - VSP Opticare OptiCare Vision Plan (Ben~E~lect) PCIP Pinnacle Claims PO Box 14079 Private Private Pay Private Pay/ VT exams billed to Blue Shiels pvt pay SafeGuard SAFEGUARD VISION SafeHeatlh Life Ins. same as before Scan See Change Health Insurance see files SMW LOCAL 104 (Health Care Plan) spectera Superior Vision Services, INC TRi- Care Tricare for LIfe - COWPS UCSC vision plan UFCW- Blue Shield UFCW valley Clerk Trust Fund Unife Here Health uNITED aMERICAN iNS. cO. United Administrative Services United Health United Health Care UNITED HEALTHCARE VIP Vision Service Plan Vision Service Plan -PEC Vision Service Plan / mes Vision Service Plan PEC Vision Service Plan X2 VPS VSA Vsion Plan for UCSC VSP VSP preferred
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 --- (Ben~E~lect) A A R P A A R P AARP AARP DISC PLAN Adventist Risk Management Aetna AETNA Vision Allied Administrators Antham Anthem Anthem Blue Cross Anthem Blue Cross anthem.com/ca Anthem Blue View Vision anthem clue cross Anthem Freedom Blue Benefits & Risk Management Services Blue Sheild of CA Blue Cross Blue Cross Anthem Freedom Blue Plan Blue Cross Blue Shield Blue Cross Blue Shield` blue cross, blue shield Blue Cross/Blue Shield BLUE Sheild of CA Blue Shield Blue Shield HMO Blue Shield of CA Blue Shield of California Blue View Vision BlueShield brms.claims.com Cabrillo Discount Cabrillo employee discount Cabrillo Host Lions Club Cabrillo Host Lions Club of Aptos Carpenters Health & Welfare cigna Cigna - CISCO City of Sebastopol CLANCEY, MARGERY COASTAL TPA Davis Vision Davis Vision/ MEDICARE DSP EJS Insurance Electrical Workers Health Local 234 Eye Med EyeMed EYEMED ECPA EyeMed Vision Care EyeMed Vision Care Discount Plan EyeMed Vision Care (NO BILLING NEEDED) EyeMed Vision Care Access Discount Plan FEP Blue Bision Freedom Blue Guardian GWH-Cigna PPO Health Net HealthNet I pay Cash IBEW LOCAL 234 (PACIFIC HEALTH) Interplan Health/Health Markets Lion's Club voucher $300 Lions Club voucher Lions Club voucher (12/28/2011) Lyons Club medica MEDICAL EYE SERVICES MEDICARE MEDICARE (EyeMed) Disc Plan Scanned in Auth Medicare and Freedom Blue mutual ins. admin inc N/A n/a I Pay Cash na No insurance None none ;{ NVA Insurance on file On file - VSP Opticare OptiCare Vision Plan (Ben~E~lect) PCIP Pinnacle Claims PO Box 14079 Private Private Pay Private Pay/ VT exams billed to Blue Shiels pvt pay SafeGuard SAFEGUARD VISION SafeHeatlh Life Ins. same as before Scan See Change Health Insurance see files SMW LOCAL 104 (Health Care Plan) spectera Superior Vision Services, INC TRi- Care Tricare for LIfe - COWPS UCSC vision plan UFCW- Blue Shield UFCW valley Clerk Trust Fund Unife Here Health uNITED aMERICAN iNS. cO. United Administrative Services United Health United Health Care UNITED HEALTHCARE VIP Vision Service Plan Vision Service Plan -PEC Vision Service Plan / mes Vision Service Plan PEC Vision Service Plan X2 VPS VSA Vsion Plan for UCSC VSP VSP preferred
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 --- (Ben~E~lect) A A R P A A R P AARP AARP DISC PLAN Adventist Risk Management Aetna AETNA Vision Allied Administrators Antham Anthem Anthem Blue Cross Anthem Blue Cross anthem.com/ca Anthem Blue View Vision anthem clue cross Anthem Freedom Blue Benefits & Risk Management Services Blue Sheild of CA Blue Cross Blue Cross Anthem Freedom Blue Plan Blue Cross Blue Shield Blue Cross Blue Shield` blue cross, blue shield Blue Cross/Blue Shield BLUE Sheild of CA Blue Shield Blue Shield HMO Blue Shield of CA Blue Shield of California Blue View Vision BlueShield brms.claims.com Cabrillo Discount Cabrillo employee discount Cabrillo Host Lions Club Cabrillo Host Lions Club of Aptos Carpenters Health & Welfare cigna Cigna - CISCO City of Sebastopol CLANCEY, MARGERY COASTAL TPA Davis Vision Davis Vision/ MEDICARE DSP EJS Insurance Electrical Workers Health Local 234 Eye Med EyeMed EYEMED ECPA EyeMed Vision Care EyeMed Vision Care Discount Plan EyeMed Vision Care (NO BILLING NEEDED) EyeMed Vision Care Access Discount Plan FEP Blue Bision Freedom Blue Guardian GWH-Cigna PPO Health Net HealthNet I pay Cash IBEW LOCAL 234 (PACIFIC HEALTH) Interplan Health/Health Markets Lion's Club voucher $300 Lions Club voucher Lions Club voucher (12/28/2011) Lyons Club medica MEDICAL EYE SERVICES MEDICARE MEDICARE (EyeMed) Disc Plan Scanned in Auth Medicare and Freedom Blue mutual ins. admin inc N/A n/a I Pay Cash na No insurance None none ;{ NVA Insurance on file On file - VSP Opticare OptiCare Vision Plan (Ben~E~lect) PCIP Pinnacle Claims PO Box 14079 Private Private Pay Private Pay/ VT exams billed to Blue Shiels pvt pay SafeGuard SAFEGUARD VISION SafeHeatlh Life Ins. same as before Scan See Change Health Insurance see files SMW LOCAL 104 (Health Care Plan) spectera Superior Vision Services, INC TRi- Care Tricare for LIfe - COWPS UCSC vision plan UFCW- Blue Shield UFCW valley Clerk Trust Fund Unife Here Health uNITED aMERICAN iNS. cO. United Administrative Services United Health United Health Care UNITED HEALTHCARE VIP Vision Service Plan Vision Service Plan -PEC Vision Service Plan / mes Vision Service Plan PEC Vision Service Plan X2 VPS VSA Vsion Plan for UCSC VSP VSP preferred
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:

None Doesn't Have One Doesn't Remember Other

Last Visit

1 week 1 month 3 months 6 months 1 year 2 years Other

Reason For Visit:

Annual Check up Illness Other

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

Good health Headaches Arthritis Asthma Arrythmia Heart Condition HTN Inflammatory Bowel Disease Seizure Disorder Preg "Now" Nursing Diagnosed As HIV+ Diabetes Type I Diabetes Type II Hypercholesteremia Hypothyroid Hyperthyroid Cancer Cancer- Breast Allergies Anemia Migraines with Aura Migraines w/o Aura Other

Pregnant Or Nursing

No Yes Unsure Other

Recent Tetanus Shot

Yes No Other

Headaches

Yes No Occasional Constant Other

Notes

Has always had headaches Has never had headaches/new event Headaches assoc with sinuses/allergies diagnosed as migraines by physician describes classic migraine headache describes classic migraine/rec to see physician headaches non specific/not severe headaches associated with vision tasks/reading headaches assoc with vision/driving or other distance tasks Other

Injuries, Surgeries, Hospitalization

past pregnancy car accident surgery Other

SYSTEMIC MEDS

Drug Allergies:

Over The Counter Meds

None Aspirin, 81mg Aspirin 325 mg Ibuprofen Acetomenophin Aleve Glucosamine Other

Vitamins

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

Occupation:

Hobbies:

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

Tobacco	No Yes Other	Type	None Chewing Tobacco Cigarettes Cigars 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

Personal Notes

REVIEW OF SYSTEMS

Do you currently have any of these problems?

GENERAL: Fever, weight loss, weight gain, fatigue?	None Negative Other
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus	None sneezing swelling redness itching hives lupus Seasonal allergies Other
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems	None bleeding cholestrolemia anemia Other
ENDORCRINE: Thyroid, Diabetes	None diabetes hypothyroid hyperthoyroid Diabetes Type I Diabetes Type II Other
PSYCHIATRIC: Depression, Anxiety, Insomnia	None anxiety depression insomnia schizophrenia Bipolar Alzheimer's Other
NEUROLOGICAL: Headaches, migraines, seizures	None numbness, paralysis headache seizures migraines head trauma Other
SKIN: growths, rashes, acne	None pimples, warts growths rash roscea acne melanoma Other
MUSCLES, BONES, JOINTS: Athritis, Joint Pains, Head or Neck Injury	None joint pain stiffness swelling cramps arthritis Other
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence	None painful urination frequent urination impotence jaundice kidney stones incontinence bladder infection Other
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD	None Asthma Bronchitis Emphysema COPD Other
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease	None High BP Surgery Vascular Disease High Cholestrol Other
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat	None Allergies Sinus Problems Chronic Cough Dry Throat / Mouth Hard of Hearing Other
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux	None Diarrhea Constipation Ulcer Acid Reflux Other

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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