New Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
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:

Primary

Primary Insurance Information
Insurance Name:
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

Secondary Insurance Information
Insurance Name:
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

Tertiary Insurance Information
Insurance Name:
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:

Supplemental

Supplemental Insurance Information
Insurance Name:
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

**Please complete all entries below, then push "submit" button on next tab to submit information to our office **



**Current/Past Eye Conditions** (check all that apply)

Vision Loss Gritty Feeling Infection Diabetic Retinopathy
Blurry Vision Itching Stie Glaucoma
Distorted Vision Excess Watering Flashes Macular Degeneration
Dry Eyes Light Sensitivity Floaters Retinal Detachment
Redness Burning Tired Eyes Double Vision
Discharge Eye Pain Cataracts


 Any other eye problems, conditions? Explain in space below.
(Night-time blurriness or halos, dry eyes, itchy eyes, computer eye strain, lumps or bumps,
eye pain or discomfort)                         
 



List any Ocular History  (Lasik, eye surgery, eye trauma, lazy eye, cataract surgery)


List any Allergies (Seasal, allergies to drugs, foods, medications)


Surgeries/Injuries (Heart surgery, trauma to head, major accidents, etc)


Medications and Eye Drops (list any medications currently taking, including eye drops)




**Social History **

Alcohol use (Y/N)    

Pregnant/Nursing? (Y/N)       

Smoking          

Rec Drugs (Y/N)     

Drives (Y/N)            

Hobbies                   
 
 

**Personal History** (select all that apply to you)


Gastrointestinal Neurological Respiratory Genitourinary
Colitis Headaches Asthma Bladder Problems
Crohns Dz Seizures Bronchitis Kidney Problems
Ulcers Migraines Emphysema STD's
Constipation Multiple Sclerosis
Diarrhea
 
Constitutional Endocrine Cardiovascular Allergic/Immune
Fever Type I Diabetes Heart Dz Drug Allergies
Weight loss/Gain Type II Diabetes High Blood Pressure Seasonal Allergies
Fatigue Thyroid Dysfunction High Cholesterol Arthritis
Trauma
 
Skin Ears/Nose/Throat Musculoskeletal Lymph/Blood
Eczema Allergies Osteoarthritis Anemia
Rosacea Dry Mouth Fribromyalgia Bleeding Problems
Psoriasis Sinus Congestion Ankylosing Spond. Leukemia

Other

**Family Medical History ** (Check if any family members have or have had condition. Specify which family member in box open box next to condition)

Blindness     Cancer
Cataracts     Diabetes
Macular Degen     Heart Dz
Glaucoma     High BP
Retinal Detach     Kidney Dz
Crossed Eyes     Arthritis
Thyroid Dz     Lupus




Submit


Thank you for taking the time to fill out our online History Questionnaire form.

You may click on each tab above to review the information you have provided.

Please be sure you have filled out BOTH the Demographics tab AND the Medical History tab and any applicable insurance tabs before clicking submit.

Please make sure to click on the "Submit Date" button below to securely submit your information.

Is is OK to call you for your yearly exam reminder?

To avoid a $25 fee, you must provide at least 24 hours notice of cancellation or rescheduling.