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. Moses, Broderick
Dr. Galos, Patricia
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:
Primary
Insurance Information
Insurance Name:
None
Always Vision
Avesis
Block Vision/Am Grp
Block Vision/Comm Health Choice
Block Vision/Health Spring
Block Vision/TXCH
Blue Cross Blue Shield
Davis Vision
Humana
MES Vision
New Insurance
Opticare Superior Texas
Opticare/BravoHealth
Opticare/Evercare
Opticare/Molina
Opticare/Superior EPOChip
Opticare/Superior HP Foster
Opticare/Visionplans
Spectera/Optum Hx
Starmount
Superior Vision
Traditional Mcaid
United Healthcare
Vision Service Plan
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:
Secondary
Insurance Information
Insurance Name:
None
Always Vision
Avesis
Block Vision/Am Grp
Block Vision/Comm Health Choice
Block Vision/Health Spring
Block Vision/TXCH
Blue Cross Blue Shield
Davis Vision
Humana
MES Vision
New Insurance
Opticare Superior Texas
Opticare/BravoHealth
Opticare/Evercare
Opticare/Molina
Opticare/Superior EPOChip
Opticare/Superior HP Foster
Opticare/Visionplans
Spectera/Optum Hx
Starmount
Superior Vision
Traditional Mcaid
United Healthcare
Vision Service Plan
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:
Tertiary
Insurance Information
Insurance Name:
None
Always Vision
Avesis
Block Vision/Am Grp
Block Vision/Comm Health Choice
Block Vision/Health Spring
Block Vision/TXCH
Blue Cross Blue Shield
Davis Vision
Humana
MES Vision
New Insurance
Opticare Superior Texas
Opticare/BravoHealth
Opticare/Evercare
Opticare/Molina
Opticare/Superior EPOChip
Opticare/Superior HP Foster
Opticare/Visionplans
Spectera/Optum Hx
Starmount
Superior Vision
Traditional Mcaid
United Healthcare
Vision Service Plan
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
Referred By:
Referring Doctor:
Any family members patients here? Who?:
Hobbies:
Interested In Contact Lenses?
No
Yes
Ever Worn Contact Lenses?
No
Yes
Type of CLs worn in past:
Disposables
Extended Wear
Gas Permeables
Gas Perm Bifocals
Gas Perm Bitorics
Gas Perm FS Toric
Monovision - Soft
Monovision - Disposables
Monovision - Gas Perm
No CL Hx
Soft Daily Wear
Soft Torics
Do you have back up glasses for your contacts?
Yes
No
Primary Vision Correction:
None
Bifocals
Contacts
Contacts - Mono
Progressives
Single Vision
Trifocals
Sunglasses?
No
Yes
Interested in Laser Vision Correction?
Not Interested
Yes
Eye Hx: Sting, Burn, Itch, Surg.,Injury,Cats, Ambly.,Floaters, GL, Strab., Retinal
Blurred Vision
None
Pain in the eye
Burning eye
Itchy eye
Red eye
Abrasion
Blind Eye
Blepheroplasty
Cataract - OU
Cataract - OD
Cataract - OS
Conjunctivitis
Glaucoma
IOL - OU
IOL - OD
IOL - OS
Metal in Eye
Ptosis
Retinal Detach
Weak Eye
Lazy Eye
None
Eye Meds:
Last Eye Doctor:
Primary Care Physician:
Systemic Meds:
Med Hx: HAs,Arthritis,Asthma,Diabetes,HBP,Heart,Infl. Bowel Dz,Seizures,Thyroid,Smoke,Pregnant,Nursing,HIV+
Family Med History:
Family Eye History:
Medication and Seasonal Allergies:
NOTES/SOCIAL HISTORY
Review of Systems
DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?
General:
None
Negative
Ears, Nose, Throat:
None
dry mouth
cough
ear ache
hard of hearing
stuffy nose
Cardiovascular:
None
High BP
racing
pulse
Respiratory:
None
congestion
short of breath
wheezing
Asthma
Emphysema
Genital, Kidney, Bladder:
None
frequent urination
impotence
painful urination
yellow jaundice
Muscles, Bones, Joints:
None
arthritis
cramps
joint pain
stiffness
swelling
Skin:
None
growths
pimples, warts
rash
Eczema
Neurological:
None
headache
numbness, paralysis
seizures
Psychiatric:
None
anxiety
depression
insomnia
Retardation
Down Syndrome
Endocrine:
None
diabetes
hypothyroid
 : Blood/Lymph:
None
anemia
bleeding
cholestrolemia
Allergic/Immunologic:
None
hives
itching
lupus
redness
sneezing
swelling
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