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
Annulled
Divorced
Domestic partner
Interlocutory
Legally Separated
Married
Never Married
Polygamous
Widowed
Employer/School Name
Primary Doctor
No Doctor Assigned
Dr. Bush, Blake
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:
Medical History
Referred By:
Walk-by/Drive-by
Insurance
Friend/Family
Website/Internet
Yellow Pages
Other
Referring Doctor:
Family Patients:
Hobbies:
Arts and Crafts
Baseball
Basketball
Boating
Bowling
Cooking
Cycling
Dancing
Exercising
Fishing
Football
Gardening
Golf
Horses
Hunting
Jogging
Lawn Work
None
Outdoors
Painting
Patient did not disclose
Photography
Piano
Reading
Running
Sailing
Scuba
Sewing
Skiing
Soccer
Softball
Swimming
T.V.
Tennis
Video Games
Wake Boarding
Weights
Woodworking
Other
Interested In Contact Lenses?
Ever Worn Contact Lenses?
Type of Contact Lenses 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
Other
Do you currently have a pair of glasses?
Yes
No
Other
Primary Vision Correction:
None
Bifocals
Contacts
Contacts - Mono
Progressives
Single Vision
Trifocals
Other
Do you currently have a pair of prescription sunglasses
Yes
No
Other
Do you routinely spend more than 4 hours per day on a computer?
Yes
No
Other
Have you noticed problems with glare from oncoming headlights?
Yes
No
Other
Are you interested in permanent Vision Correction? (LASIK, PRK, RLE)
Not Interested
Yes
Other
Eye Hx: Sting, Burn, Itch, Surg.,Injury,Cats, Ambly.,Floaters, GL, Strab., Retinal
None
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
No Significant Eye Hx
Other
Eye Meds:
None
Acular
Artificial Tears
Betoptic-S .25%
Betoptic .5%
Betagan
Erythromycin
FML
FML Forte
Gentamicin
Neosporin
Ocupress
Pilo Gel
Propine
Polytrim
Pred Mild
Pred Forte
Patanol
Timoptic .25%
Timoptic .5%
Tobradex
Voltaren
Xalatan
Other
Last Eye Doctor:
Patient Does not Recall
(first eye exam)
Clay
Hobbs
Martin
Parker
Ross
Rushing
Wells
Other
Primary Care Physician:
Med Hx: HAs,Arthritis,Asthma,Diabetes,HBP,Heart,Infl. Bowel Dz,Seizures,Thyroid,Smoke,Pregnant,Nursing,HIV+
Healthy Medical History
Asthma
Allergies
Artheritis
Cancer
Depression
Food Allergy
Gout
Hypertension
Hypercholesterolemia
Herpes
Migraines
Pregnant
Pollen Allergy
Thyroid Dis. - Hypo
Thyroid Dis. - Hyper
Diabetes - Type 1
Diabetes - Type 2
Other
Family Med History:
Family History unremarkable
None Known
Artheritis
Cancer
Diabetes I
Diabetes II
Hypertension
Hypercholesterolmia
Heart Dx
Other
Family Eye History:
No Significant Family Eye History
Amblyopia
Cataracts
Glaucoma
Macular Degeneration
Retinal Detachment
Weak Eye
Lazy Eye
Other
Medication and Seasonal Allergies:
NKDA
Erythromycin
Iodine
Pollen
PCN
Sulfa
Codeine
Tetanus
Other
NOTES/SOCIAL HISTORY
Systemic Meds:
Review of Systems
General:
None
Negative
Other
Ears, Nose, Throat:
None
dry mouth
cough
ear ache
hard of hearing
stuffy nose
Other
Cardiovascular:
None
High BP
racing
pulse
Other
Respiratory:
None
congestion
short of breath
wheezing
Other
Genital, Kidney, Bladder:
None
frequent urination
impotence
painful urination
yellow jaundice
Other
Muscles, Bones, Joints:
None
arthritis
cramps
joint pain
stiffness
swelling
Other
Skin:
None
growths
pimples, warts
rash
Other
Neurological:
None
headache
numbness, paralysis
seizures
Other
Psychiatric:
None
anxiety
depression
insomnia
Other
Endocrine:
None
diabetes
hypothyroid
no problem
Other
Blood/Lymph:
None
anemia
bleeding
cholestrolemia
Other
Allergic/Immunologic
None
hives
itching
lupus
redness
sneezing
swelling
Other
Additional Medical History Notes
Primary Insurance
Insurance Information
Insurance Name:
None
AARP
Aetna
Allied National
American Retirement Life Ins Co
Assurant Health/ASA
Blue Cross Blue Shield of Oklahoma
Boon-Chapman Benefit Administrators Inc
ChampVA
Cigna
Coventry Health Care
Coventry Health Care of Kansas, Inc
Eyemed Select
Global Health
GPA
Great Cornerstone LIfe and Health Insurance Company
Health Choice
Health Smart Preferred Care
Humana
Humana Vision Services
Medicare
Medicare DME
Medicare Supplement
Medico Insurance Company
Mutual Assurance Administrators
New Insurance
Omaha Insurance Company
Oxford Life Ins Company
Preferred Community Choice
Primary Vision Care Services
Principal Life Insurance Co
QTC
Reserve National Insurance Co
Sedgwick Claims Management Services, Inc
Soonercare
Spectera
State Farm Health Insurance
Superior Vision Services
The Kempton Group
Tricare
TriWest WPS-VAPCCC
UMR
United Health Care
United Teacher Associates Ins Co
Vision Care Direct
Vision Service Plan signature
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
AARP
Aetna
Allied National
American Retirement Life Ins Co
Assurant Health/ASA
Blue Cross Blue Shield of Oklahoma
Boon-Chapman Benefit Administrators Inc
ChampVA
Cigna
Coventry Health Care
Coventry Health Care of Kansas, Inc
Eyemed Select
Global Health
GPA
Great Cornerstone LIfe and Health Insurance Company
Health Choice
Health Smart Preferred Care
Humana
Humana Vision Services
Medicare
Medicare DME
Medicare Supplement
Medico Insurance Company
Mutual Assurance Administrators
New Insurance
Omaha Insurance Company
Oxford Life Ins Company
Preferred Community Choice
Primary Vision Care Services
Principal Life Insurance Co
QTC
Reserve National Insurance Co
Sedgwick Claims Management Services, Inc
Soonercare
Spectera
State Farm Health Insurance
Superior Vision Services
The Kempton Group
Tricare
TriWest WPS-VAPCCC
UMR
United Health Care
United Teacher Associates Ins Co
Vision Care Direct
Vision Service Plan signature
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
AARP
Aetna
Allied National
American Retirement Life Ins Co
Assurant Health/ASA
Blue Cross Blue Shield of Oklahoma
Boon-Chapman Benefit Administrators Inc
ChampVA
Cigna
Coventry Health Care
Coventry Health Care of Kansas, Inc
Eyemed Select
Global Health
GPA
Great Cornerstone LIfe and Health Insurance Company
Health Choice
Health Smart Preferred Care
Humana
Humana Vision Services
Medicare
Medicare DME
Medicare Supplement
Medico Insurance Company
Mutual Assurance Administrators
New Insurance
Omaha Insurance Company
Oxford Life Ins Company
Preferred Community Choice
Primary Vision Care Services
Principal Life Insurance Co
QTC
Reserve National Insurance Co
Sedgwick Claims Management Services, Inc
Soonercare
Spectera
State Farm Health Insurance
Superior Vision Services
The Kempton Group
Tricare
TriWest WPS-VAPCCC
UMR
United Health Care
United Teacher Associates Ins Co
Vision Care Direct
Vision Service Plan signature
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:
Submit Data
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