New Patient Form

Please fill out as much information as possible before clicking the 'Submit' button on the last tab. We can add information when you come in to the office, but we appreciate anything you can type in on this page. (Please note: this is a secure webpage provided by Crystal Practice Management.)

Demographics

TitleFirstLastMISuffixNickname
Address:
City:
State/ZipCode
Home Phone:
Work Phone:
Other Phone:
SSN
Email
Birthday
Occupation
Sex Male Female
Employment Status Employed Full-Time Student Part-Time Student None of the Above
Marital Status
Employer/School Name
Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Vision Insurance

Vision 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:
Employer/School:

Medical Insurance

Medical 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:
Employer/School:

Medical History


Name of Primary Care Physician (PCP):
Last Visit to PCP:

Medications

Medication Allergies

Environmental/Seasonal Allergies


PATIENT MEDICAL HISTORY:

Are you pregnant or nursing?

Do you get headaches?
If yes, please explain:

Please list any Injuries, Hospitalizations, or Surgeries (including those related to your eyes):


REVIEW OF SYSTEMS:
Mark 'Yes' if there is an issue in one of the following categories and our optometric technician will ask about the details when you come in for your appointment.

GENERAL: Fever, weight loss, weight gain, fatigue, etc.?

EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat, etc.?

CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease, etc.?

RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD, etc.?

GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence, etc.?

MUSCLES, BONES, JOINTS: Athritis, Joint Pains, Head or Neck Injury, etc.?

SKIN: growths, rashes, acne, etc.?

NEUROLOGICAL: Headaches, migraines, seizures, etc.?

PSYCHIATRIC: Depression, Anxiety, Insomnia, etc.?

ENDORCRINE: Thyroid, Diabetes, etc.?

BLOOD/LYMPH: Anemia, cholesterol, bleeding problems, etc.?

ALLERGIC / IMMUNOLOGIC: Rheumatoid, AIDS, Allergy Shots, Lupus, etc.?

GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux, etc.?

Do you have a Sexually-Transmitted Disease (STD)?

FAMILY MEDICAL HISTORY:


SOCIAL HISTORY
Occupation:

Hobbies:


How should we contact you for future appointments?

Do you currently or have you ever used any tobacco products?

Do you use any recreational or illegal drugs?

Submit


Please click the 'Submit Data' button below after finishing the other tabs. Thank you!