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:

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