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:
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
Unknown
Single
Married
Separated
Divorced
Widowed
Child
Employer/School Name
Primary Doctor
No Doctor Assigned
Dr. ORM III, OD, GEORGE
Dr. Gerard, Stephanie
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:
Vision Insurance
Insurance Information
Insurance Name:
None
Avesis
Block Vision
Davis
EyeMed
Medicaid
Medicare
Molina
Spectera
Superior Vision
VCP (Humana Vision)
VSP
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:
Medical Insurance
Insurance Information
Insurance Name:
None
Aetna
BCBS
Beech Street
Cigna
First Health
Great West
Humana
Medicare
Medicaid
Tricare
United Healthcare
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:
Other Insurance
Insurance Information
Insurance Name:
None
Avesis
Block Vision
Davis
EyeMed
Medicaid
Medicare
Molina
Spectera
Superior Vision
VCP (Humana Vision)
VSP
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:
Medical History
Do you have a history of any of the following? If multiple answers, please provide one answer for each line:
Good health
Arthritis
Asthma
Diabetes
HBP
Headaches
Heart Condition
HX Of Drug/Alcohol Abuse
Inflammatory Bowel Disease
Smoking
Seizure Disorder
Thyroid Disease
Preg "Now"
Nursing
Diagnosed As HIV+
Do you have a history of:
None
Arthritis
Diabetes
HBP
Heart disease
Cancer
Lupus
Kidney
Thyroid
Back Problems
Do you have a history of:
None
Athritis
Diabetes
HBP
Heart Disease
Cancer
Lupus
Kidney Disease
Thyroid Disease
Back Problems
Do you have a history of:
None
Arthritis
Diabetes
HBP
Heart Disease
Cancer
Lupus
Kidney
Thyroid
Back Problems
Do you have a history of:
None
Arthritis
Diabetes
HBP
Heart Disease
Cancer
Lupus
Kidney
Thyroid Disease
Back Problems
Do you have a history of:
None
Arthritis
Diabetes
HBP
Heart Disease
Cancer
Lupus
Kidney Disease
Thyroid
Back Problems
Please list any Injuries, Surgeries, or Hospitalizations
Are you pregnant or nursing?
No
Yes
Unsure
Have you had a recent tetanus shot?
Yes
No
Name of Primary Care Physcian:
Last Visit:
1 week
1 month
3 months
6 months
1 year
2 years
greater than two years
Reason For Visit:
Check up
Annual
Other
Please check if you are not currently on any medications
Please check if you do not have any allergies to any medications
Please list prescription medications you currently take:
Please list over the counter medications you take:
Please list any vitamins you take:
Family Medical History-please select from options below. If muliple, please write in spaces provided.
None
Adopted
Diabetes
HBP
Cancer
Cardiovascular Disease
Athritis
Kidney Disease
Lupus
Thyroid
Family Medical History
Family Medical History
Family Medical History
Family Medical History
Family Medical History
What do you do for a living?
Hobbies:
Astronomy
Art
Baseball
Boating
Basketball
Cooking
Crafts
Dancing
Diving
Football
Fishing
Golf
Gardening
Horseback Riding
Hunting
Models
Needlepoint
None
Painting
Photography
Piano
Reading
Running
Roller Blading
Softball
Sewing
Skiing
Soccer
Swimming
Tennis
Video Games
Woodworking
Do you smoke?
Never Smoker
Current every day smoker
Current some day smoker
Former smoker
Smoker, currernt status unknown
Unknown if ever smoked
What do you smoke?
None
Cigarettes
Chewing Tobacco
How much do you smoke?
Do you drink alcohol?
No
Yes
Occasionally
Socially
What type of alcohol do you drink?
None
Beer
Wine
Hard Liquor
All the Above
How many drinks do have during the week?
Do you use illegal drugs?
No
Yes
What type of drugs do you use?
How often do you use illegal drugs?
Have you ever had a sexually transmitted disease? Please answer yes or no and if yes list below:
Review of Systems
GENERAL: Do you experience any of the following: fever, weight loss, weight gain, fatigue
None
Negative
Fever
Weight Loss
Weight Gain
Fatigue
Multiple
EAR, NOSE, THROAT: Do you experience any of the following: allergies, sinus, cough, dry Mouth / throat
None
Allergies
Sinus Problems
Chronic Cough
Dry Throat / Mouth
Hard of Hearing
Multiple
CARDIOVASCULAR: Do you experience any of the following: High BP, Heart Surgery, Vascular Disease
None
Vascular Disease
HBP
Heart Surgery
All the above
Multiple
RESPIRATORY: Do you experience any of the following: Asthma, Bronchitis, Emphysema, COPD
None
Asthma
Bronchitis
Emphysema
COPD
Multiple
GENITAL, KIDNEY, BLADDER: Do you experience any of the following: Kidney Stones, Frequent Urination, impotence
None
painful urination
frequent urination
impotence
yellow jaundice
multiple
MUSCLES, BONES, JOINTS: Do you experience any of the following: Arthritis, Joint Pains, Head or Neck Injury
None
joint pain
stiffness
swelling
cramps
arthritis
SKIN: Do you experience any of the following: growths, rashes, acne
None
pimples, warts
growths
rash
NEUROLOGICAL: Do you experience any of the following: Headaches, migraines, seizures
None
numbness, paralysis
headache
seizures
migraines
multple
PSYCHIATRIC: Do you experience any of the following: Depression, Anxiety, Insomnia
None
anxiety
depression
insomnia
multiple
ENDORCRINE: Do you experience any of the following: Thyroid, Diabetes
None
diabetes
hypothyroid
hyperthoyroid
diabetes and thryoid
BLOOD/LYMPH: Do you experience any of the following: Anemia, cholesterol, bleeding problems
None
bleeding
cholestrolemia
anemia
multiple
ALLERGIC / IMMUNOLOGIC: Do you experience any of the following: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus
None
sneezing
swelling
redness
itching
hives
lupus
GASTROINTESTINAL: Do you experience any of the following: Diarrhea, Constipation, Ulcer, Reflux
None
Diarrhea
Constipation
Ulcer
Acid Reflux
Chief Complaint
What brings you in to see us?
blurred vision
red eye
pain in eye
loss of vision
injury to eye
needs new glasses
wants to be fitted for contacts
itching
burning
stinging
dry eyes
Diabetic eye exam
annual doctor directed diabetic eye exam
failed screening at school
failed test at pediatrician's office
broken glasses
Location:
Both
Right
Left
Severity:
Mild
Moderate
Severe
Quality:
no change
worse
better
constant
throbbing
Duration:
1 day
2 days
3 days
4 days
5 days
6 days
1 week
1 month
3 months
6 months
1 year
couple of months
years
Timing:
Always
Sometimes
AM
PM
comes and goes
Context:
computer
outside
night
distance and near
near
distance
Modifying:
Medication
Glasses help
Drops help
CLs help
Associated:
dizzy
headache
loss of vision
blurred vision
eye pain
Is there anything else that you have experienced with your eyes? Please describe below:
Ocular History: Have you been diagnosised with or experienced any of the following?
None
Amblyopia
Burning, Stinging
Cataracts
Itching
Flashes Of Light
Floaters
Glaucoma
Macular Degeneration
Retinal Detachment
Retinal Disorders
Strabismus
Multiple
Are you on any eye medications?
None
Cromolyn NA 4%
Visine
Patanol
Xalatan
Travatan
rewetting drops
Elestat
Vigamox
Alphagan
Refresh
Theratears
Genteal
Pred Forte
Lotemax
Alrex
Systane
Blink
1 year
2 years
3 years
greater than 3 years>/option>
Name of Last Eye Doctor:
Do you have a family history of Glaucoma?
No
Sibling
Mother
Father
Parents
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Grandparents
Aunt
Uncle
Do you have a family history of Cataracts?
No
Sibling
Mother
Father
Parents
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Grandparents
Aunt
Uncle
Do you have a family history of Macular Degeneration?
No
Sibling
Mother
Father
Parents
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Grandparents
Aunt
Uncle
Do you have a family history of Retinal Detachment?
No
Sibling
Mother
Father
Parents
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Grandparents
Aunt
Uncle
Do you have any family history of a Crossed / Lazy eye?
No
Sibling
Mother
Father
Parents
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Grandparents
Aunt
Uncle
What is your primary vision correction?
None
Glasses-Full Time
Glasses-Readers Only
Contacts - Soft
RGPs
PMMA
Do you have backup glasses?
Yes
No
Planning to get new glasses?
Yes
No
CONTACT LENSES
None
Acuvue Oasys
Acuvue Oasys for Astigmatism
Acuvue TruEye
Acuvue 1-day Moist
Acuvue 1-day Moist for Astigmatism
Acuvue Oasys for Presbyopia
Acuvue Advanced Plus
Acuvue 2
Air Optix N&D
Air Optix Aqua
Air Optix for Astigmatism
Air Optix MF
Avaira
Avaira Toric
Biofinity
Biofinity Toric
Biofinity MF
Biotrue
Dailies Aqua Comfort Plus
Dailies Toric
Freshlook
Freq 55
Limbal FS
Proclear
Proclear 1 day
Purevision2
Purevision MF
Optima FW
O2 Optix
SL 66
SL66 Toric
SL66 MF
Total Dailies 1
2 Clear
Rigid Gas Permeable
Synergeyes
Wear Time:
8 - 10 Hours
All day
Occ. Overnight
Extended
Cleaner:
Aquify
Biotrue
Boston
Clear Care
Optifree
Renu
Revitalens
Disposal:
2 weeks
monthly
daily
weekly
yearly
Race:
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Ethnicity:
Non Hispanic or Latino
Hispanic or Latino
Preferred Language:
English
French
German
Spanish
Other
If your a diabetic please list your last blood sugar and HbA1C:
Is there anything you would like your doctor to know before your exam?
Have you had any eye surgeries?
None
Cataract
ICL
LASIK
Glaucoma
PRK
Retinal
Strabismus
Multiple
Have you had any eye injuries?
No
Yes
Submit Data
After Completing All Forms Submit Data on Final Tab