New Patient Form

Demographics and History

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
Misc/Guardian
Preferred Language: Height: ft in Weight: lbs
Race:
Please list hobbies or daily activities:

Date of last eye exam: Doctor's name:
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?
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:
Do you use tobacco products?
Yes No If yes, type/amount/how often:
Hobbies
Student
GradeSchool

EYES
Do you have a history of any of the following?
Do you experience any of the following?
Condition Yes No
Blindness
Eye Turn (Strabismus)
Lazy Eye (Amblyopia)
Patching
Glaucoma
Cataracts
Macular Degeneration
Retinal Detachment
Eye Surgery
Eye Injury
Condition Yes No
Blurred Vision
Burning
Eyes feel dry
Double Vision
Eyes Tear
Eye Hurt or Tired
Flashes
Floaters
Foreign Body Sensation
Eyes Itch
Bothered by Light/Sunlight
Halos Around Lights
Redness
Eyes Feel Sandy/Gritty
Mucous Discharge


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:

FAMILY HISTORY Family history is unknown/adopted

History Of The Following In Any Family Members (Parents, Grandparents, Siblings, Children)?


Condition Yes No Relationship To Patient
Lazy Eye (Amblyopia)
Blindness
Cataracts
Glaucoma
Condition Yes No Relationship To Patient
Retinal Detachment
Macular Degeneration
High Blood Pressure
Diabetes

Insurance Information

Primary Insurance

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:


Secondary Insurance

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Submit Data

After Completing All Forms Submit Data on Final Tab