New Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
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:

Medical History

Do you have any medical problems involving the following areas?
Respiratory
Ear/ Nose/ Throat
Immunologic
Endocrine:
Lymph Nodes/ Blood Disorders
Bones / Muscles/ Joints
Skin/ Dermatologic
Genitourinary
Gastrointestinal
Neurological
Fever/ Weight Loss or Gain
Psychiatric/ Social
Vascular/Cardiovascular
Do you use tobacco products?
Do you use illicit drugs?
Do you drink alcohol?
Are you currently pregnant or nursing?
Are you being treated for high blood pressure?
Are you being treated for diabetes?
Have you been exposed to any infectious diseases? (TB, HIV)
Preferred Language
Ethnicity
Race
Primary Care Doctor
Last Physical Exam
Please list any other medical issues:
Please list any injuries or surgeries to your body?
Estimated Weight (pounds)
Estimated Height (feet)
(inches)
Do you or any blood relatives have any of the following health or eye problems?
Diabetes
High Blood Pressure
Heart Problems
Thyroid Disease
Cancer
Glaucoma
Macular Degeneration
Retinal Disease
Corneal Disease
Explain if needed:
Have you ever had an eye injury, eye surgery or other serious eye problem?
Explain:
When was your last eye exam?
Were your eyes dilated at your last eye exam?
Are you seeing flashes of light or floating spots?
Do you have severe or frequent heachaches or eye pain?
Do you CURRENTLY wear contact lenses?
Are you here to be fitted for contacts today?
What brand of contacts do you wear?
Which contact lens solution do you use?
How long do you wear your contacts?
How often do you change your contacts?

Submit Data

After Completing All Forms Submit Data on Final Tab