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 Vision Insurance

Insurance Information
Insurance Name:
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:

Secondary Vision Insurance

Insurance Information
Insurance Name:
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

Insurance Information
Insurance Name:
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:

Secondary Medical Insurance

Insurance Information
Insurance Name:
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:

Misc Insurance

Insurance Information
Insurance Name:
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:

Reason for Visit


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Reason for Visit
What would you like the doctor to address at your visit?Secondary Issues:

Patient History


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Patient Ocular History
Eye Diseases or Conditions Eye Injuries
Eye Medications:Over The Counter Eye Medications:
Eye Vitamins: Interested in LASIK?

Vision Correction
Ever worn glasses? Need new glasses? Have back up glasses?

Wear contact lenses? Contact lens type: Contact Lens Wear Time:
Replacement Schedule: Extended Wear Time: Need New Contact Lenses?
Care System:
NOTES:

Personal Medical History
Pregnant or Nursing:  NoYes       Due Date

Drug Allergies:           No known drug allergies

Environmental Allergies:

Current Medications and DropsMedical ConditionsDose/Frequency/Route
No current medications                 Recreational Drug Use?

Family Ocular History
Adopted: Family History Unknown

Cataracts: Retinal Detachment: Glaucoma: Vision Loss: Macular Degeneration:
Notes:

Family Medical History
Cancer: Inherited Diseases: Diabetes: Heart Disease: Other:
Notes:


Review of Systems


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

Patient Information
Primary Care Physcian: Last Visit: Reason For Visit:
Location/Address:

Injuries, Surgeries, Hospitalizations:

Latest A1c Controlled? Tx:

Race Ethnicity Preferred Language

Height:  Ft. In.     Weight:  Lbs.     Blood Pressure:  /  

Social History
Smoking Status: Discussed Cessation?                 General Mood or affect:

Do you drink alcohol?

Review of Systems
GENERAL: Fever, Fatigue, Weight Loss/Gain
EAR, NOSE, THROAT: HOH, Allergies, Sinus Problems, Dry Throat/Mouth, Cough
CARDIOVASCULAR: High BP, stroke, Heart Surgery, Vascular Disease
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD
KIDNEY, BLADDER: Kidney Stones, Frequent/Painful Urination
MUSCLES, BONES, JOINTS: Arthritis, Joint Pain/Stiffness, Head or Neck Injury
SKIN: Rosacea, Growths, Rashes, Acne
NEUROLOGICAL: Headaches, Migraines, Seizures
PSYCHIATRIC: Depression, Anxiety, Insomnia
BLOOD/LYMPH: Anemia, Cholesterol, Bleeding Problems
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid Arthritis, HIV/AIDS, Lupus
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux
ENDORCRINE: Diabetes, Hyper/Hypothyroid


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