New Patient Form
Demographics and History
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Rev.
Fr.
Miss
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
Single
Married
Separated
Divorced
Widowed
Unknown
Employer/School Name
Misc/Guardian
Preferred Language:
Height:
ft
in
Weight:
lbs
Race:
Declined
American Indian or Alaskan Native
Black or African American
Hispanic or Latino
Native Hawaiian or Pacific Islander
White
Please list hobbies or daily activities:
Date of last eye exam:
Doctor's name/Office Location:
How did you learn about our office?
Family and Friends
Waller Family Eyecare Website
Yahoo
Facebook
Google
Other
Are you Interested in Contact Lenses?
Yes
No
Have you ever worn contact lenses?
Yes
No
Contact Lens Wearers:
Are your lenses comfortable?
Yes
No
Current Brand:
What solution do you use?
What is your replacement schedule?
Daily
Weekly
Every 2 weeks
Monthly
Quarterly
Yearly
How old is your current pair?
SOCIAL HISTORY
This information is required by insurance carriers and is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer. If so, check here:
Smoking Status
Current Every Day Smoker
Current Some Day Smoker
Former Smoker
Never Smoker
Smoker, Current Status Unknown
Unknown if Ever Smoked
Do you drink alcohol?
Yes
No
If yes, type/amount/how often:
Do you use illegal drugs?
Yes
No
If yes, type/amount/how often:
Are you currently or have you ever been infected with:
Tuberculosis
Yes
No
Hepatitis
Yes
No
HIV
Yes
No
Syphilis
Yes
No
Chlamydia
Yes
No
Herpes
Yes
No
EYES
Eye Surgery/Injury?
No History of Eye Surgery or Injury
History of Eye Surgery
History of Eye Injury
Eye History?
No Significant Ocular History
Lazy Eye
Glaucoma
Cataracts
Macular Degeneration
Retinal Detachment
Eye Turn (Strabismus)
Lazy Eye
MEDICAL HISTORY / REVIEW OF SYSTEMS:
Primary Care Physician:
Last visit
BP
Do you have any allergies to medications?
Yes
No
If yes, please list:
Are you pregnant or nursing?
Yes
No
N/A
Do you currently have, or are you being treated for, any of the following conditions?
SELECT "YES" TO ALL THAT APPLY TO YOU
1- CONSTITUTIONAL:
Fever
Yes
No
Weight Loss/ Gain
Yes
No
Other
2- INTEGUMENTARY (SKIN):
Herpes Zoster (Shingles)
Yes
No
Eczema
Yes
No
Rosacea
Yes
No
Other
3- NEUROLOGICAL:
Migraines
Yes
No
Seizures
Yes
No
Multiple Sclerosis
Yes
No
Other
4- ENDOCRINE:
Thyroid problems
Yes
No
Diabetes
Yes
No
Other
5- ALLERGIC/ IMUNOLOGIC:
Drug Allergy
Yes
No
Environmental Allergy
Yes
No
Lupus
Yes
No
Other
6- RESPIRATORY:
Asthma
Yes
No
Bronchitis
Yes
No
Emphysema
Yes
No
Other
7- EAR/ NOSE/ THROAT:
Allergies/Hay fever
Yes
No
Chronic Cough
Yes
No
Sinus Congestion
Yes
No
Other
8- CARDIOVASCULAR:
Heart Disease
Yes
No
High blood pressure
Yes
No
Stroke
Yes
No
Vascular Disease
Yes
No
Other
9- GASTROINTESTINAL:
Crohn's
Yes
No
Colitis
Yes
No
Ulcer
Yes
No
Other
10-GENITOURINARY:
Genital/ Kidney/ Bladder
Yes
No
Other
11- MUSCULOSKELETAL:
Arthritis
Yes
No
Fibromyalgia
Yes
No
Muscular Dystrophy
Yes
No
Other
12- HEMATOLOGIC/ LYMPHATIC:
Anemia
Yes
No
Leukemia
Yes
No
Bleeding Problems
Yes
No
Other
13- PSYCHIATRIC:
Depression
Yes
No
Panic Disorder
Yes
No
Schizophrenia
Yes
No
Other
List of your current medication:
No current medications
FAMILY HISTORY
Family history is unknown/adopted
Family Medical History
None
High Blood Pressure
Diabetes
Thyroid Disease
Cancer
Family Ocular History
Glaucoma
Cataracts
Lazy Eye
Eye Turn-Strabismus
Retinal Detachment or Disease
Mascular Degeneration
None
Insurance
Insurance Information
If someone other than you carries the insurance plan, please complete:
Primary Insured Name:
Last, First MI
Relationship to Patient:
Spouse
Child
Other
Birthday:
SSN:
Submit Data
After Completing All Forms Submit Data on Final Tab