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:

Vision Insurance

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:

Medical Insurance

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:

Other Insurance

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:

Medical History

Do you have a history of any of the following? If multiple answers, please provide one answer for each line:
Do you have a history of:
Do you have a history of:
Do you have a history of:
Do you have a history of:
Do you have a history of:
Please list any Injuries, Surgeries, or Hospitalizations
Are you pregnant or nursing?
Have you had a recent tetanus shot?
Name of Primary Care Physcian:
Last Visit:
Reason For Visit:
Please check if you are not currently on any medicationsPlease 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.
Family Medical History
Family Medical History
Family Medical History
Family Medical History
Family Medical History
What do you do for a living?
Hobbies:
Do you smoke?
What do you smoke?
How much do you smoke?
Do you drink alcohol?
What type of alcohol do you drink?
How many drinks do have during the week?
Do you use illegal drugs?
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
EAR, NOSE, THROAT: Do you experience any of the following: allergies, sinus, cough, dry Mouth / throat
CARDIOVASCULAR: Do you experience any of the following: High BP, Heart Surgery, Vascular Disease
RESPIRATORY: Do you experience any of the following: Asthma, Bronchitis, Emphysema, COPD
GENITAL, KIDNEY, BLADDER: Do you experience any of the following: Kidney Stones, Frequent Urination, impotence
MUSCLES, BONES, JOINTS: Do you experience any of the following: Arthritis, Joint Pains, Head or Neck Injury
SKIN: Do you experience any of the following: growths, rashes, acne
NEUROLOGICAL: Do you experience any of the following: Headaches, migraines, seizures
PSYCHIATRIC: Do you experience any of the following: Depression, Anxiety, Insomnia
ENDORCRINE: Do you experience any of the following: Thyroid, Diabetes
BLOOD/LYMPH: Do you experience any of the following: Anemia, cholesterol, bleeding problems
ALLERGIC / IMMUNOLOGIC: Do you experience any of the following: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus
GASTROINTESTINAL: Do you experience any of the following: Diarrhea, Constipation, Ulcer, Reflux

Chief Complaint


What brings you in to see us?
Location:
Severity:
Quality:
Duration:
Timing:
Context:
Modifying:
Associated:
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?
Are you on any eye medications?
Name of Last Eye Doctor:
Do you have a family history of Glaucoma?
Do you have a family history of Cataracts?
Do you have a family history of Macular Degeneration?
Do you have a family history of Retinal Detachment?
Do you have any family history of a Crossed / Lazy eye?
What is your primary vision correction?
Do you have backup glasses?
Planning to get new glasses?
CONTACT LENSES
Wear Time:
Cleaner:
Disposal:
Race:
Ethnicity:
Preferred Language:
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?
Have you had any eye injuries?

Submit Data

After Completing All Forms Submit Data on Final Tab