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
Misc/Guardian

Family Medical History

Check the box if someone in your family has or had any of the following conditions. Family members to consider are siblings, parents, and grandparents.

Amblyopia

Blindness

Cataract

Color Blindness

Glaucoma

Macular Degeneration

Retinal Detachment

Strabismus (Eye turn)

Arthritis

Cancer

Diabetes

Heart Disease

HTN

Kidney

Lupus

Stroke

Thyroid

Other

Patient Medical History

In the first box indicate if the patient has any problems in this area. In the second box list any medications the patient is taking for the condition.

Example:

Respiratory

asthma				inhaler

Fever over 105.0

Weight Loss

Other Const. Symptoms

Ear, Nose, Throat

Cardiovascular

Respiratory

Gastrointestinal

Genital/Bladder/Kidney

Muscles/Bones/Joints

Skin

Neurological

Psychiatric

Diabetes/Thyroid

Cholesterol/Anemia

Allergies/Immunological

Pregnant or Nursing

Medications Allergic to

Patient Current Eye Symtoms

Please check the box if you have a history of:

Cataract
Color Blindness
Glaucoma
Macular Degeneration
Retinal Detachment


Please check the box of any eye symptoms you are currently experiencing.

Headache
Light Sensitive
Tired Eyes
Burn/Dry/Watery
Foreign Body/Sandy
Itch/Red
Blurred Distance
Blurred Near
Double Vision
Flashes/Floaters
Amblyopia
Strabismus

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