New Patient Form

Demographics

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

Address1:
Address2:
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:
SSN*
*SSN of primary name on insurance policy. Needed for insurance verification only.
Email
Birthday
Occupation
Sex	Male Female
Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Unknown Single Married Separated Divorced Widowed Child
Employer/School Name
Primary Doctor	Dr. Howard, Dana
Misc/Guardian

Billing Information

Is The Billing Address the Same?

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

Address1
Address2
City
State	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
ZipCode
Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None Aetna Blue Cross Blue Shields Cigna Comp Benefits (Vision Care) Davis Vision Eyemed Humana Medicare Opticare Optum Health Vision Other Superior Vision T.R. Paul United Healthcare Vision Service Plan (Signature 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:
Employer/School:

Secondary

Insurance Information

Insurance Name:	None Aetna Blue Cross Blue Shields Cigna Comp Benefits (Vision Care) Davis Vision Eyemed Humana Medicare Opticare Optum Health Vision Other Superior Vision T.R. Paul United Healthcare Vision Service Plan (Signature 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:
Employer/School:

Tertiary

Insurance Information

Insurance Name:	None Aetna Blue Cross Blue Shields Cigna Comp Benefits (Vision Care) Davis Vision Eyemed Humana Medicare Opticare Optum Health Vision Other Superior Vision T.R. Paul United Healthcare Vision Service Plan (Signature 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:
Employer/School:

Medical History

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Referred By:
Pregnant	No Yes
Smoker	No Yes Sometimes
Primary Vision Correction:	None Single Vision Glasses Progressives Contacts Contacts-Monovision Contacts-Multifocals Bifocals Trifocals
Interested In Contact Lens?	No Yes
Problems with current Contacts?
Interested in LASIK?	Not Interested Yes
Problems with glare?	No Yes
Last Eye Exam:	1 year 6 months 2 years 3 years Not sure
EyeTrauma:	No Yes
Eye Surgery:	No Yes
Vision Loss:	No Yes
Double Vision:	No Yes
Flashes:	No Yes
Floaters:	No Yes
Excess tearing:	No Yes
Burning:	No Yes
Itching:	No Yes
Glaucoma:	No Yes
Cataracts:	No Yes Had surgery to remove
Other:
Eye Meds:	None Acular Alrex Artificial Tears Artificial Tears-Refresh Artificial Tears-Soothe Betoptic-S .25% Betoptic .5% Betagan Erythromycin FML FML Forte Gentamicin Lotemax Neosporin Ocupress Optivar Pilo Gel Propine Polytrim Pred Mild Pred Forte Patanol Restasis Timoptic .25% Timoptic .5% Tobramycin Tobradex Vigamox Voltaren Xalatan Zaditor Zymar Zylet
Systemic Meds:
Allergies:
Primary Care Physician:
Last Physical Exam:	1 year not sure
Hypertension:	No Yes-Controlled Yes-Uncontrolled
Cholesterol:	No Yes Borderline
Diabetes:	No Border line Yes-Under control Yes-Not controlled
Heart Dz:	No Mitral Valve Prolapse Congestive Heart Failure Heart Attack Stroke Bypass Surgery Endocarditis
Thyroid:	No Hypo Hyper Hashimoto's Dz Grave's Dz
Lung Disease:	No Asthma Emphysema
Arthritis:	No Age Related Injury Related Rheumatoid Juvenile Rheumatoid
Auto Immune:	No Lupus
Skin:	No Dermatitis Psoriasis Vitiligo
Gastric:	No Reflux IBS Ulcers Fundoplication Stomach Reduction Sx
Urogenital:	No Kidney Dz Kidney Stones Prostate Cancer Urinary Tract Infection
Cancer:	No Lung Cancer Breast Cancer Colon Cancer
Psychiatric:	No Depression Anxiety Bipolar Disorder Manic Depression Schizophrenia
Neurological:	No Epilepsy Brain Tumor
Blood:	No Anemia Leukemia Hemophelia
General Health:
Family Medical History:
Family Eye History:
NOTES:

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