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?
EAR, NOSE, THROAT:
CARDIOVASCULAR:
RESPIRATORY:
GENITAL, KIDNEY, BLADDER:
MUSCLES, BONES, JOINTS:
SKIN:
NEUROLOGICAL:
PSYCHIATRIC:
ENDORCRINE:
BLOOD/LYMPH:
ALLERGIC / IMMUNOLOGIC:
GASTROINTESTINAL:
Primary Care Physcian:
Over the Counter Medications:
No meds
Vitamins:
No Known Drug Allergies
Injuries, Surgeries, Hospitalization
Pregnant Or Nursing:
Ocular History (including injury, surgery or eye disease)
Eye Meds:
Last Eye Exam:
Glaucoma:
Cataracts:
Macular Degen:
Retinal Detach:
Crossed / Lazy Eye:
Primary Vision Correction:
Type of CLs worn in past:
Cleaner:
Disposal:
Contact Brand
Wear Time:
Day/week
Race:
Ethnicity:
Preferred Language:
Family Medical History (Adopted, Diabetes, High Bloop Pressure, Cancer, Lupus, Thyroid, Cardiovascular Disease etc)
Family Medical History 2 (Diabetes, High Bloop Pressure, Cancer, Lupus, Thyroid, Cardiovascular Disease etc)
Family Medical History 3 (Diabetes, High Bloop Pressure, Cancer, Lupus, Thyroid, Cardiovascular Disease etc)
Family Medical History 4 (Diabetes, High Bloop Pressure, Cancer, Lupus, Thyroid, Cardiovascular Disease etc)
Family Medical History 5 (Diabetes, High Bloop Pressure, Cancer, Lupus, Thyroid, Cardiovascular Disease etc)
Family Medical History 6 (Diabetes, High Bloop Pressure, Cancer, Lupus, Thyroid, Cardiovascular Disease etc)
Occupation:
Hobbies:
Smoking Status:
Type:
How Long:
Alcohol:
Type:
How Long:
Illegal Drugs:
Type:
Sexually Transmitted Diseases: