New Patient Form

Demographics

Title First Last MI Suffix Nickname

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:
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. Lew-Goltz, Joanne	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix

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:

Medical Insurance 1

Insurance Information

Insurance Name:	None Advantica (vision insurance) Alaska Care (vision, medical insurance) Always Vision (vision insurance) Americhoice (medical insurance) Avesis (vision insurance) Blue Cross Blue Shield (medical insurance) CHP+ (vision, medical insurance) CNIC/Intercare (vision, medical insurance) Davis Vision/FEP BCBS (vision insurance) Div. of Vocational Rehabilitation (vision) Eye and Ear Program (vision) Medicaid (vision, medical insurance) Medicare (medical insurance) MES Vision (vision insurance) Multiplan (medical insurance) National Vision Admin (vision insurance) Other insurance not listed (see notes) Oxford Health Plans (medical insurance) Pacificare (medical insurance) QTC (vision) Rocky Mountain Health Plan (vision, medical insurance) San Juan Medical Center (vision, medical insurance) Spectera/Optum Health (vision insurance) Superior Vision (vision insurance) United Health Care (vision, medical insurance) VSP out-of-network plan (vision insurance)
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 2

Insurance Information

Insurance Name:	None Advantica (vision insurance) Alaska Care (vision, medical insurance) Always Vision (vision insurance) Americhoice (medical insurance) Avesis (vision insurance) Blue Cross Blue Shield (medical insurance) CHP+ (vision, medical insurance) CNIC/Intercare (vision, medical insurance) Davis Vision/FEP BCBS (vision insurance) Div. of Vocational Rehabilitation (vision) Eye and Ear Program (vision) Medicaid (vision, medical insurance) Medicare (medical insurance) MES Vision (vision insurance) Multiplan (medical insurance) National Vision Admin (vision insurance) Other insurance not listed (see notes) Oxford Health Plans (medical insurance) Pacificare (medical insurance) QTC (vision) Rocky Mountain Health Plan (vision, medical insurance) San Juan Medical Center (vision, medical insurance) Spectera/Optum Health (vision insurance) Superior Vision (vision insurance) United Health Care (vision, medical insurance) VSP out-of-network plan (vision insurance)
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:

Vision Insurance

Insurance Information

Insurance Name:	None Advantica (vision insurance) Alaska Care (vision, medical insurance) Always Vision (vision insurance) Americhoice (medical insurance) Avesis (vision insurance) Blue Cross Blue Shield (medical insurance) CHP+ (vision, medical insurance) CNIC/Intercare (vision, medical insurance) Davis Vision/FEP BCBS (vision insurance) Div. of Vocational Rehabilitation (vision) Eye and Ear Program (vision) Medicaid (vision, medical insurance) Medicare (medical insurance) MES Vision (vision insurance) Multiplan (medical insurance) National Vision Admin (vision insurance) Other insurance not listed (see notes) Oxford Health Plans (medical insurance) Pacificare (medical insurance) QTC (vision) Rocky Mountain Health Plan (vision, medical insurance) San Juan Medical Center (vision, medical insurance) Spectera/Optum Health (vision insurance) Superior Vision (vision insurance) United Health Care (vision, medical insurance) VSP out-of-network plan (vision insurance)
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

DATE OF LAST EYE EXAM

BY WHOM?
Never Dr. Joanne Lew-Goltz, O.D. Can't remember other

How did you hear about us?
Walk-in Family/friend Physician referral Insurance Yellow Pages Radio Internet search Other

We send out reiminders for your next exam. How do you want us to contact you for future exam reminders?
Email address that I entered in my demographics Mail a card Phone call Mobile text I do not want any reminders

Who is your family doctor?

Primary Vision Correction:
None Glasses-Full Time Glasses-Distance Only Glasses-Readers Only Contacts - Soft Contacts - Gas Perm Contacts- keratoconus other

Brand names of CLs worn in past:
None Acuvue 2 Acuvue Advance Acuvue Oasys Air Optix Aqua Avaira Baush Lomb SofLens Biofinity Biomedics/Ultraflex Dailies Aquacomfort Focus Dailies Frequency Freshlook Colors/Colorblends Hydrasoft Night and Day O2Optix Proclear Purevision rigid gas permeable contact contact for keratconus other
Other CL brands I have worn in the past:

If you do not wear contacts, would you like to try contacts?
No Yes
Occupational tasks, sports, hobbies that require vision correction

HEIGHT(required)
Feet:
Inches:
WEIGHT (required)

This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.
Yes, I prefer to discuss this portion directly with the doctor.
Tobacco:(Y/N)
Never smoker (<100 cigs equiv) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day)
Alcohol:(Y/N)
No Yes
Amount
1-2 glasses 3-4 glasses 5-6 glasses
How Often?
1-2 times/dy 1-2 times/wk 1-2 times/mos rarely
Illegal Drugs:
No Yes
Have you ever been exposed or infected w/STDs?
No Gonorrhea Syphilis Hepatitis HIV TB
Pregnant Or Nursing?:
No Yes Unsure
List past EYE diseases, infections, injuries or surgeries


List other Major Injuries, Surgeries, Hospitalization


*DRUG ALLERGIES*


MEDICATIONS


FAMILY HISTORY:
(indicate Relationship in the drop down box)
Blindness
none mother father brother sister grandmother grandfather aunt uncle cousin
Glaucoma
none mother father brother sister grandmother grandfather aunt uncle cousin
Cataract
none mother father brother sister grandmother grandfather aunt uncle cousin
Macular Degeneration
none mother father brother sister grandmother grandfather aunt uncle cousin
Crossed Eyes
none mother father brother sister grandmother grandfather aunt uncle cousin
Retinal Disease
none mother father brother sister grandmother grandfather aunt uncle cousin
Please type in any other FAMILY problem not listed above
none mother father brother sister grandmother grandfather aunt uncle cousin

ETHNICITY:
American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Hispanic or Latino Other Race Unknown Patient Declined to Specify




REVIEW OF SYSTEMS:

DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?
EYES:
Loss of Vision(blackout)
Blurred Vision
Distorted Vision/Halos
Dryness
Mucous Discharge
Redness
Sandy or gritty feeling
Itching
Burning
Excess tearing
Glare or light sensitivity
Eye pain or soreness
Chronic infection of eye or lid
Styes
SKIN:
Growths
Rashes
NEUROLOGICAL:
Headaches
Migraines
Seizures
ENDOCRINE:
Thyroid problem or other glands
EAR, NOSE, THROAT:
Allergies/Hay fever
Sinus congestion
Chronic cough
Dry throat or mouth
RESPIRATORY:
Asthma
Bronchitis or COPD
CARDIOVASCULAR:
Diabetes
Heart problems
High blood pressure
High cholesterol
GASTROINTESTINAL:
Crohn's Disease
KIDNEY, BLADDER:
Kidney problems
MUSCLES, BONES, JOINTS:
Rheumatoid arthritis
BLOOD/LYMPH:
Anemia
Bleeding problems
ALLERGIC / IMMUNOLOGIC:
Lupus
PSYCHIATRIC:
Additional Notes: