New Patient Form

Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev. Fr. Miss

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	Single Married Separated Divorced Widowed Unknown	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. McGuirt, G.R. Dr. Outside Doctor, See Notes Job Order	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Fr. Miss

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

PATIENT MEDICAL HISTORY: HAs, Arthritis, Asthma, Diabetes, HBP, Heart, Infl. Bowel Dz, Seizures, Thyroid

Injuries, Surgeries, Hospitalization

None

Primary Care Physcian:

Doesn't Remember Doesn't Have One None

Last Visit:

Unknown 1 week 1 month 3 months 6 months 1 year 2 years

Reason For Visit:

Annual Check up

Glaucoma Meds

Alphagan P betimol betoptic cosopt Istalol lumigan Lumigan Pilocarpine 2% Timoptic Travatan Z Trusopt Unknown Xalatan

Eye Meds:

None acular Alrex bacitracin Bepreve Blink ciloxan Elestat erythromycin FML gentamicin Genteal Lotemax Maxitrol Muro 128 no reported ocular meds ocuflox Pataday Patanol polytrim Pred Forte Refresh refresh ointment Refresh/Optive restasis rewetting drops Systane Theratears Tobradex tobramycin Vigamox Visine zaditor zylet Zymaxid Moxeza

OTC:

None Acetomenophin artificial tears Asprin Ibuprofen napcon A opcon A Visine

FAMILY MEDICAL HISTORY: Diabetes, HBP, Heart Dz, Cancer, Athritis, Lupus, Kidney, Thyroid, Other

None Adopted Athritis Cancer Cardiovascular Disease Diabetes HBP Kidney Disease Lupus Thyroid

fmh2

None Adopted Athritis Cancer Cardiovascular Disease Diabetes HBP Kidney Disease Lupus Thyroid

fmh3

None Adopted Athritis Cancer Cardiovascular Disease Diabetes HBP Kidney Disease Lupus Thyroid

fmh4

None Adopted Athritis Cancer Cardiovascular Disease Diabetes HBP Kidney Disease Lupus Thyroid

fmh5

None Adopted Athritis Cancer Cardiovascular Disease Diabetes HBP Kidney Disease Lupus Thyroid

fmh6

None Adopted Athritis Cancer Cardiovascular Disease Diabetes HBP Kidney Disease Lupus Thyroid

Occupation:

Hobbies:

Astronomy Art Baseball Boating Basketball Cooking Crafts Dancing Diving Football Fishing Golf Gardening Horseback Riding Hunting Models Needlepoint None Painting Photography Piano Reading Running Roller Blading Softball Sewing Skiing Soccer Swimming Tennis Video Games Woodworking

Tobacco:

Yes No

Type:

None Current Every Day Smoker Current Some Day Smoker Former Smoker Smoker Unknown status

How Long:

Less then pack/day >1 year 1pack a day> 1year More the 1 pack a day > 1 year recently started

Pt fully oriented to time, place, and person. Recent and remote memeory is fully intactPt is plesant and sociable

Other disposition notes

Discussed Cessation

Yes No

See ARRA for MEDSSee ARRA for AllergiesNon SmokerNO MedsNo Allergies

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