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	Unknown Single Married Separated Divorced Widowed Child	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Hill, Nicki Dr. Floyd, David	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:

Vision

Insurance Information

Insurance Name:	None AEA Disc Plan Aetna All Kids Avesis BCBS FED DISC Blue Cross Blue Shield Coast to Coast Davis Vision Eyemed Humana (VCP) Medicaid Medicare Southland State Emp Disc Superior Tricare Viva Health VSP
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

Insurance Information

Insurance Name:	None AEA Disc Plan Aetna All Kids Avesis BCBS FED DISC Blue Cross Blue Shield Coast to Coast Davis Vision Eyemed Humana (VCP) Medicaid Medicare Southland State Emp Disc Superior Tricare Viva Health VSP
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 AEA Disc Plan Aetna All Kids Avesis BCBS FED DISC Blue Cross Blue Shield Coast to Coast Davis Vision Eyemed Humana (VCP) Medicaid Medicare Southland State Emp Disc Superior Tricare Viva Health VSP
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

Decreased distance vision?	Yes No	Decreased near vision?	Yes No
Decreased computer vision?	Yes No	Night glare or halos?	Yes No
Dry Eyes?	Yes No	Itchy Eyes?	Yes No
Red Eyes?	Yes No	Burning or stinging?	Yes No
Sensitive to light?	Yes No	Tearing or watering?	Yes No
Do you see flashes of light?	Yes No	Do you see floaters?	Yes No

                    

 

 

 

Do you have headaches? Yes No If yes, how often? Where? Frontal Temporal Behind Eyes Back of head

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: Last Visit: 1 week 1 month 3 months 6 months 1 year 2 years Reason For Visit: Check up Annual
List any Vitamins you take:
Please list any over the Counter medications:
Please list your current Prescription Medications: No Current Medications
Please list all drug allergies: No Known Drug Allergies

FAMILY MEDICAL HISTORY
Do you have a history of any of the following in your family? (Please select from the drop downs below.)
None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid None Adopted Diabetes HBP Cancer Cardiovascular Disease Arthritis Kidney Disease Lupus Thyroid None Adopted Diabetes HBP Cancer Cardiovascular Disease Arthritis Kidney Disease Lupus Thyroid None Adopted Diabetes HBP Cancer Cardiovascular Disease Arthritis Kidney Disease Lupus Thyroid
None Adopted Diabetes HBP Cancer Cardiovascular Disease Arthritis Kidney Disease Lupus Thyroid None Adopted Diabetes HBP Cancer Cardiovascular Disease Arthritis Kidney Disease Lupus Thyroid
Occupation: Hobbies:
Smoking Status: Never Smoker Current every day smoker Current some day smoker Former smoker Smoker, current status unknown Unknown if ever smoked Type: None Cigarettes Chewing Tobacco How Long:
Alcohol: No Yes Occasionally Socially Type: 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 Cromolyn NA 4% Visine Patanol Xalatan Travatan rewetting drops Elestat Vigamox Alphagan Refresh Theratears Genteal Pred Forte Lotemax Alrex Systane Blink
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 specs? Yes No

Type of CLs 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:

Preferred Language: English French German Spanish  Ethnicity:  Non Hispanic or Latino Hispanic or Latino  Race:  American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White
 

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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