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. Barnes, Charolette Dr. Reis, Gayle Dr. MA, YEN Dr. WALPORT, AMY Dr. PARISI, LEANNA Dr. SJAW, STEPHANIE	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:

Primary

Insurance Information

Insurance Name:	None AETNA BEN-E-LECT BLUE CROSS HEALTHY FAMILIES EPO BLUE CROSS OF CALIFORNIA BLUE CROSS/BLUESHIELD OF UTAH BLUE SHIELD BLUECROSS CARD CALIFORNIA VISION PROJECT CASH CIGNA HEALTHCARE COLE VISION COMPBENEFITS VISIONCARE DAVIS VISION DEPARTMENT OF RISK MANAGMENT DIRECT REIMBURSEMENT BENEFITS PLANS DISCOUNT PLANS E.B.A CORPORATION ECPA EXCLUSIVE CARE EYEMED DISCOUNT PLAN EYEMED VISION CARE GEHA HEALTHNET HUMANA IEHP IEHP HEALTHY KID IEHP MEDICARE DUAL CHOICE IPM HEALTH & WEALTHFARE TRUST LABORERS HEALTH & WELFARE TRUST MARCH MD CARE MARCH VISION MEDI-CAL MEDI-MEDI MEDICARE J1 MAC-PALMETTO MEDIVERSAL MES MOLINA MEDICARE OPTION PLUS NATIONAL VISION ADMINISTRATORS NATIONWIDE SPECIALTY HEALTH NORIDIAN PAN AMERICAN LIFE PRINCIPAL LIFE RELIANCE STANDARD LIFE INSURANCE RISK MANAGMENT SAFEGUARD SAFEGUARD DISCOUNT PLAN SAFEGUARD SMILESAVER 10 SAFEGUARD SMILESAVER 20/20 SAFEGUARD SMILESAVER 30 SPECTERA CLAIMS DEPARTMENT SUPERIOR VISON PLAN TRICARE TRIWEST WPS TRIDENT TRISTAR UFCW UNITED HEALTH CARE UNITEDHEALTHCARE Unknown Import VILLAGE HEALTH - MEDICARE VISION CARE PLAN VISION ONE DISC. VSP ACCESS VSP ADVANTAGE VSP CHOICE PLAN VSP COVERED CONTACTS VSP EXAM PLUS ALLOWANCE VSP GIFT CERTIFICATE VSP HEALTHY FAMILY VSP MEDICAID VSP REGIONAL NETWORK VSP SIGHT FOR STUDENTS VSP SIGNATURE VSP SIGNATURE CHOICE VSP STATE OF CA VSP VALUE PLAN
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 AETNA BEN-E-LECT BLUE CROSS HEALTHY FAMILIES EPO BLUE CROSS OF CALIFORNIA BLUE CROSS/BLUESHIELD OF UTAH BLUE SHIELD BLUECROSS CARD CALIFORNIA VISION PROJECT CASH CIGNA HEALTHCARE COLE VISION COMPBENEFITS VISIONCARE DAVIS VISION DEPARTMENT OF RISK MANAGMENT DIRECT REIMBURSEMENT BENEFITS PLANS DISCOUNT PLANS E.B.A CORPORATION ECPA EXCLUSIVE CARE EYEMED DISCOUNT PLAN EYEMED VISION CARE GEHA HEALTHNET HUMANA IEHP IEHP HEALTHY KID IEHP MEDICARE DUAL CHOICE IPM HEALTH & WEALTHFARE TRUST LABORERS HEALTH & WELFARE TRUST MARCH MD CARE MARCH VISION MEDI-CAL MEDI-MEDI MEDICARE J1 MAC-PALMETTO MEDIVERSAL MES MOLINA MEDICARE OPTION PLUS NATIONAL VISION ADMINISTRATORS NATIONWIDE SPECIALTY HEALTH NORIDIAN PAN AMERICAN LIFE PRINCIPAL LIFE RELIANCE STANDARD LIFE INSURANCE RISK MANAGMENT SAFEGUARD SAFEGUARD DISCOUNT PLAN SAFEGUARD SMILESAVER 10 SAFEGUARD SMILESAVER 20/20 SAFEGUARD SMILESAVER 30 SPECTERA CLAIMS DEPARTMENT SUPERIOR VISON PLAN TRICARE TRIWEST WPS TRIDENT TRISTAR UFCW UNITED HEALTH CARE UNITEDHEALTHCARE Unknown Import VILLAGE HEALTH - MEDICARE VISION CARE PLAN VISION ONE DISC. VSP ACCESS VSP ADVANTAGE VSP CHOICE PLAN VSP COVERED CONTACTS VSP EXAM PLUS ALLOWANCE VSP GIFT CERTIFICATE VSP HEALTHY FAMILY VSP MEDICAID VSP REGIONAL NETWORK VSP SIGHT FOR STUDENTS VSP SIGNATURE VSP SIGNATURE CHOICE VSP STATE OF CA VSP VALUE PLAN
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 AETNA BEN-E-LECT BLUE CROSS HEALTHY FAMILIES EPO BLUE CROSS OF CALIFORNIA BLUE CROSS/BLUESHIELD OF UTAH BLUE SHIELD BLUECROSS CARD CALIFORNIA VISION PROJECT CASH CIGNA HEALTHCARE COLE VISION COMPBENEFITS VISIONCARE DAVIS VISION DEPARTMENT OF RISK MANAGMENT DIRECT REIMBURSEMENT BENEFITS PLANS DISCOUNT PLANS E.B.A CORPORATION ECPA EXCLUSIVE CARE EYEMED DISCOUNT PLAN EYEMED VISION CARE GEHA HEALTHNET HUMANA IEHP IEHP HEALTHY KID IEHP MEDICARE DUAL CHOICE IPM HEALTH & WEALTHFARE TRUST LABORERS HEALTH & WELFARE TRUST MARCH MD CARE MARCH VISION MEDI-CAL MEDI-MEDI MEDICARE J1 MAC-PALMETTO MEDIVERSAL MES MOLINA MEDICARE OPTION PLUS NATIONAL VISION ADMINISTRATORS NATIONWIDE SPECIALTY HEALTH NORIDIAN PAN AMERICAN LIFE PRINCIPAL LIFE RELIANCE STANDARD LIFE INSURANCE RISK MANAGMENT SAFEGUARD SAFEGUARD DISCOUNT PLAN SAFEGUARD SMILESAVER 10 SAFEGUARD SMILESAVER 20/20 SAFEGUARD SMILESAVER 30 SPECTERA CLAIMS DEPARTMENT SUPERIOR VISON PLAN TRICARE TRIWEST WPS TRIDENT TRISTAR UFCW UNITED HEALTH CARE UNITEDHEALTHCARE Unknown Import VILLAGE HEALTH - MEDICARE VISION CARE PLAN VISION ONE DISC. VSP ACCESS VSP ADVANTAGE VSP CHOICE PLAN VSP COVERED CONTACTS VSP EXAM PLUS ALLOWANCE VSP GIFT CERTIFICATE VSP HEALTHY FAMILY VSP MEDICAID VSP REGIONAL NETWORK VSP SIGHT FOR STUDENTS VSP SIGNATURE VSP SIGNATURE CHOICE VSP STATE OF CA VSP VALUE PLAN
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

PATIENT MEDICAL HISTORY
Please select any problems you may have from the drop downs below.
Good health Arthritis Asthma Diabetes HBP Headaches Heart Condition HX Of Drug/Alcohol Abuse Inflammatory Bowel Disease Smoking Seizure Disorder Thyroid Disease Preg "Now" Nursing Diagnosed As HIV+ Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Disease Thyroid Back Problems Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Thyroid Disease Back Problems Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Thyroid Back Problems Athritis Diabetes HBP Heart Disease Cancer Lupus Kidney Disease Thyroid Disease Back Problems Diabetes HBP Heart disease Cancer Arthritis Lupus Kidney Thyroid Back Problems

Please list any Injuries, Surgeries, Hospitalization

Pregnant Or Nursing: No Yes Unsure Recent Tetanus Shot: Yes No

Notes:

Primary Care Physician: Phone: Fax: Last Visit: 1 week 1 month 3 months 6 months 1 year 2 years

Reason For Visit: Annual Physical Visit for a specific problem Check up    List any Vitamins you take:

FAMILY MEDICAL HISTORY
Please enter any family medical history in the box provided.


Occupation: Hobbies:

Smoking Status: Never Smoker Current every day smoker Current some day smoker Former smoker Smoker, currernt status unknown Unknown if ever smoked Type: None Cigarettes Cigars Pipes Chewing Tobacco How Long:

Alcohol: No Yes Occasionally Socially Type: ALL None Beer Wine Hard Liquor How Long:

Illegal Drugs: No Yes Type: How Long: STD: None Gonorrhea Syphilis Hepatitis HIV TB

PATIENT OCULAR HISTORY
Please select if you have had any of the following: Itching Burning, Stinging Amblyopia Eye Injuries Eye Surgery Flashes Of Light Floaters Strabismus Cataracts Glaucoma Retinal Disorders None

Please select your current Eye Meds: None Pataday Patanol Latacaft Elestat Alaway Lotemax Alrex Refresh Systane Blink rewetting drops Visine Genteal Xalatan Alphagan Travatan Pred Forte Vigamox Cromolyn NA 4% Other

Last Eye Doctor: Last Eye Exam: 1 year 2 years 3 years over 3 years
 
FAMILY OCULAR HISTORY

Glaucoma: No Parents Sibling Grandparent Crossed / Lazy: No Parents Siblings Grandparent Retinal Detach: No Parents Siblings Grandparent Macular Degeneration: No Parents Siblings Grandparent Cataracts: No Parents Siblings Grandparent

Primary Vision Correction:  None Glasses-Full Time Glasses-Readers Only Contacts - Soft RGPs PMMA  Planning to get new glasses? Yes No  Back up spectacles? Yes No

Type of Contact Lenses worn in past: None Disposable Conventional Colored RGP PMMA  Wear Time: 8 - 10 Hours All day Occ. Overnight Extended Cleaner: Optifree Clear Care Boston Renu Disposal: 2 weeks monthly daily weekly yearly

NOTES:

Are you currently using eye drops?   Ethnicity:  Non Hispanic or Latino Hispanic or Latino  Eye Surgeries: 

DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?

GENERAL: Fever, weight loss, weight gain, fatigue?
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury
SKIN: growths, rashes, acne
NEUROLOGICAL: Headaches, migraines, seizures
PSYCHIATRIC: Depression, Anxiety, Insomnia
ENDOCRINE: Thyroid, Diabetes
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, M.S., Lupus, HIV
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

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