New Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone:
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
Billing Information PLEASE COMPLETE IF BILLING INFORMATION IS DIFFERENT THAN ABOVE.
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Primary Medical Insurance

Insurance Information
Insurance Name:
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 Medical Insurance

Insurance Information
Insurance Name:
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:

Vision Insurance

Insurance Information
Insurance Name:
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

Insurance Information
Insurance Name:
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:

Fourth Insurance

Insurance Information
Insurance Name:
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


How did you hear about our office, if by an individual who can we thank?

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Eye History

Last Eye Exam:

Eye Surgery:


Eye Conditions:
Recurrent Corneal Erosion Amblyopia Glaucoma Dry Eye Syndrome Cataracts
Corneal Ulcer Keratoconus Lazy Eye Macular Degeneration

Do You currently wear
Glasses
Contact Lenses
Brand/Type/Use:

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Medical History

Medications: Rx, Over The Counter & Supplements-Please include Frequency, Dosage and How Taken
(include eye drops, vitamins, herbals, birth control)


Allergies
Animals Seasonal
Other Allergies (including medications)-Please List:


Primary Physician's Name:

Primary Physician's Phone:

Date of Last Exam:


Have you had any Surgeries-Please List:

__________________________________________________________________________________________________________________________________________________________________
Review of Systems

Do you have any of the following health problems (check the box if yes)?
Ear/Nose/Throat Cardiovascular Cancer Blood/Lymph Arthritis
Muscle/Bone Kidney/Bladder Immunological Gastrointestinal(Digestive) Endocrine (Hormones)
Skin Respiratory Psychological Pregnant Neurological(Nerves)
Unusual weight loss or gain Cholesterol Thyroid

Diabetes
Type I
Type II
Last Blood Sugar Reading:

Last A1c:


Do you have High Blood Pressure:

Any History of Seizures

What is your current Weight?

What is your current Height?


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Family History

Is there a family history of any of the following (check the box if yes)? Family History Unknown
Heart Disease Glaucoma Diabetes Cataracts Blindness
Macular Degeneration Lazy Eye Inherited Diseases High Blood Pressure

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Social History

What is your history with Smoking?


Do you use alcohol?
Drinks per week?


What is your occupation:


What are the Activities, Sports and Hobbies you enjoy?:


What is your preferred language:

What is your race:

What is your ethnicity:


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Computer Vision Questionaire

If you experience any of these symptoms, please indicate the level of discomfort:
Headaches:

Burning Eyes:

Poor Distance/Driving Vision after long use:

Squinting:

Fatigue/Tired:

Neck/Shoulder/Back Pain:

Halos:

Double Vision:

Words Run Together:

Dry/Sore Eyes:

Need Breaks/Rest:



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DRY EYE HISTORY

Do You Experience The Following? (Rate on the scale 0=Never, 1=Rarely, 2=Sometimes, 3=Often, 4=Always)
Sensitivity to light

Gritty/sandy feeling

Painful or sore eyes

Blurred vision

Poor vision


Are You Limited In Performing The Following? (Rate on the scale 0=Never, 1=Rarely, 2=Sometimes, 3=Often, 4=Always)
Reading

Driving at night

Computer use

Watching TV


Are You Uncomfortable In The Following? (Rate on the scale 0=Never, 1=Rarely, 2=Sometimes, 3=Often, 4=Always)
Windy conditions

Low humidty

Air conditioning

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