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

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

For drop down menus, please select "Other" to type in your own information.

Last Medical Exam:
Doctor:
City:

Insurance:

Vision Plan:
Med Insurance:
Primary Care Provider:

Do you know your family history? yes no Other

Diabetes	self mother father sibling maternal grandmother maternal grandfather paternal grandmother paternal grandfather none Other
High Blood Pressure	self mother father sibling maternal grandmother maternal grandfather paternal grandmother paternal grandfather none Other
Thyroid Condition	self mother father sibling maternal grandmother maternal grandfather paternal grandmother paternal grandfather none Other
Heart Disease	self mother father sibling maternal grandmother maternal grandfather paternal grandmother paternal grandfather none Other
Cancer	self mother father sibling maternal grandmother maternal grandfather paternal grandmother paternal grandfather none Other
Pregnant/Nursing:	yes no n/a Other
Major Injuries and/or Surgeries:	None car accident broken arm broken leg head trauma herniated discs hip replacement knee replacement knee surgery shoulder surgery tonsillectomy ear tubes sinus surgery appendectomy hernia repair gastric by-pass lap band hemorrhoidectomy cholecystectomy prostatectomy mastectomy C-section D&C hysterectomy ovariectomy coronary stent coronary bypass pacemaker pacemaker/defribrillator heart valve repair aneurism Other
Other Medical History:	None acid reflux acne rosacea Alzheimer's dz ankylosing spondylitis anxiety asthma atherosclerosis atrial fib autism benign prostatic hyperplasia bipolar carpal tunnel syndrome Celiac dz chronic fatigue cluster headaces congestive heart failure COPD Crohn's dz dementia depression diverticulitis Down syndrome eczema emphysema endometriosis epilepsy erectile dysfunction fibromayalgia gallstones GERD gonorrhea gout heart attack hepatitis herpes simplex HIV/AIDS hypercholesterolemia hyperlipidemia hypertriglyceridemia IBS insomnia kidney dz kidney stones migraine multiple sclerosis myasthenia gravis osteoarthritis Parkinson'd dz polycystic ovary syndrome psoriasis rheumatoid arthritis sarcoidosis schizophrenia shingles sinusitis sleep apnea systemic lupus (SLE) TB temporal arteritis vertigo Other

Review of Systems:

General:	good fever fatigue loss of appetite weight gain weight loss Other
Ear/Nose/Throat:	Denies cough, congestion, earache, soar throat None chronic cough congestion daytime drowsiness dry mouth/throat gasp while sleeping headache hearing problems heavy snoring morning headaches runny nose sinus problems sleep apnea toothache Other
Cardiovascular:	None chest pain racing heartbeat shortness of breath swollen feet/ankles TIAs Other
Pulmonary:	None chronic cough cyanosis productive cough shortness of breath wheezing Other
Genital/Urunal:	None overactive bladder painful urination underactive bladder urgency in urination urinary incontinence Other
Gastrointestinal:	None bloody stools bronzing of skin constipation dark urine diarrhea gastric reflux (GERD) jaundice nausea vomiting Other
Endocrine:	None change in appetite cold intolerance excess thirst frequent urination hair loss heat intolerance hypothyroid increased sweating Other
Musculo/Skeletal:	None decreased range of motion joint pain muscle cramps pain/tenderness stiffness swelling weakness Other
Skin:	None acne blisters cysts dandruff eczema erythema growths nodules psoriasis rash scales seborrheic / actinic keratosis ulcerations warts Other
Neurological:	None balance problems dementia memory problems muscle weakness numbness speech problems tremors vertigo tingling personality changes Other
Psychological:	None anxiety changes in eating habits changes in sex drive compulsive delusions depression excess anger excessive worrying frequent mood changes hallucinations insomnia obsessive paranoia social withdrawal substance abuse suicidal violence Other
Hem/Lymph:	None bleeding bleeding gums cuts slow to clot easy bruising heavy periods hx of significant blood loss jaundice nosebleeds pale skin pounding in ears rapid hearbeat shortness of breath Other
Immune:	None asthma hives itching mild allergy symptoms redness severe allergy symptoms sneezing swelling Other

Smoking Status:	Never smoker (<100 cigs equiv) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Unknown if ever smoked Other
What tobacco products do you use?	cigarettes pipe chew Other
Year Quit:
Alcohol Use:	None occasional social 1-2 drinks/day several drinks/day abuse Other
Drug Use:	None marijuanna daily weekly monthly cocaine heroine previous drug abuse crystal meth Other
Do you have any known drug allergies?	Yes No Other

Current Medications (if taking multiple, please select 'Other/Multiple' and write in the name(s) of your medication(s), separated by commas):
None Other/Multiple Accupril / Quinapril Aciphex / rabeprazole Actonel / risedronate Actos Acyclovir Adderall Advair Diskus Albuterol Allegra / fexofenadine alprazolam Altace / ramipril Amaryl / glimepiride Ambien / zolpidem Amiodarone amlodipine amoxicillin Aricept / donepezil Arimidex / Anastrozole Atacand / candesartan atenolol Augmentin Avandia / rosiglitazone Avapro / irbesartan azithromycin BCP Buspar Captopril Carbamazepine Casodex / bicalutamide Celebrex Celexa / celecoxib Cialis Cipro / ciprofloxacin citalopram Clarinex / desloratadine Clonidin Combivent / albuterol-ipratropium Coreg / carvedilol Coumadin / warfarin Cozaar / losartan Crestor Depakote Detrol / tolterodine Diclofenac Dilantin Diovan / valsartan Ditropan XL / oxybutynin Effexor / venlafaxine Evista / raloxifene Exelon / rivastigmine Flomax / tamsulosin Flonase / fluticasone Flovent / fluticasone Fosamax / alendronate furosemide gabapentin Glucophage / metformin Glucotrol / Glipizide Glyburide HCTZ Humulin / insulin hydrocodone-acetaminophen Hydrocortisone Hyzaar losartan Lanoxin / digoxin Lantus / insulin Lasix Lescol / fluvastatin Levaquin / levofloxacin levothyroxine Levoxyl Lexapro / escitalopram Lipitor / atorvastatin lisinopril Lotensin / benazepril Lotril / amlodipine-benazepril metformin Methlyprednisolone metoprolol Mobic / meloxicam Monpril / fosinopril Nasacort Nasonex / mometasone Neurontin / gabapentin Nexium / esomeprazole Norvasc / amlodipine Novalog omeprazole Oxycodone Oxycontin / oxycodone Paxil / paroxetine Pepcid Plaquenil Plavix / clopidogrel Pletal / cilostazol Pravachol / pravastatin Prednisone Premarin / estrogen Prempro Prevacid / lansoprazole Prilosec / omeprazole Procar / finasteride Protonix / pantoprazole Proventil Prozac Risperdal / risperidone Ritalin Seroquel / quetiapine sertraline simvastatin Singulair / montelukast Synthroid / levothyroxine Tetracycline Topamax Toprol / metoprolol Tricor / fenofibrate Ultracet / tramadol-acetominophen Valium Viagra / sildenafil warfarin Wellbutrin / bupropion Xanax Zantac Zestril Zetia / ezetimibe Zithromax / azithromycin Zocor / simvastatin Zoloft / sertraline zolpidem Zyrtec

Medication Allergies and Other Allergies:

Vitamins/Supplements (if taking multiple, please select 'Other/Multiple' and write in the name(s) of your vitamins(s), separated by commas):
None Other/Multiple Multi-vitamins Vit A Vit B Complex Vit B12 Vit C Vit D Vit E biotin Calcium Fe Mg Mn Zn Biotears Fish Oil Flax Evening Primrose oil Borage oil Glucosamine Chondroitin MSM niacin CoQ10 zeaxanthin Lutein iCaps Lutein & Omega 3 Macula Complete Ocuvite / I-caps Preservision AREDS 2 Preservision Ginko-Biloba resveratrol St John's wort Red Yeast Rice Juice+ curcumin garlic green tea extract probiotic Stinging nettle

Ocular History

For drop down menus, please select "Other" to type in your own information.

Reason for visit?

Last Eye Exam
Doctor
City

Visual Needs:

Do you currently wear?	glasses soft contact lenses gas perm. contact lenses both glasses and contact lenses no eyewear Other
If you wear contacts, how often do you wear them?	daily extended special occasions sleep in them n/a Other
Are you interested in contacts?	astigmatism daily disposables special occasions sports soft lenses monovision multifocal myopia control RGP Other
Do you have backup glasses?	Yes No Other
Please list current eye drops that you use:	None Restasis Visine Optive Theratears Systane Balance Other

Ocular History:
Do you or a family member have the following eye conditions?

Glaucoma:	self mother father sibling maternal grandmother maternal grandfather paternal grandmother paternal grandfather none Other
Eye Turn:	self mother father sibling maternal grandmother maternal grandfather paternal grandmother paternal grandfather none Other
Cataracts:	self mother father sibling maternal grandmother maternal grandfather paternal grandmother paternal grandfather none Other
Blindness:	self mother father sibling maternal grandmother maternal grandfather paternal grandmother paternal grandfather none Other
Amblyopia:	self mother father sibling maternal grandmother maternal grandfather paternal grandmother paternal grandfather none Other
Retinal Detachment:	self mother father sibling maternal grandmother maternal grandfather paternal grandmother paternal grandfather none Other

Do you have a history of an eye injury or surgeries?	None LASIK Cataract Surgery Anti-VEGF tx blepharoplasty corneal transplant filtering procedure focal laser grid laser laser trabeculoplasty LPI peripheral retinal laser PRK PRK PRP ptosis repair RD repair RK scleral buckle SLT strab sx YAG cap Other
Other Ocular History:	None choroidal nevus episcleritis chalazia frequent styes corneal ulcers GPC keratoconus Fuch's endothelial dystrophy uveitis Other

Other demographic information:

Race:	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Patient Declined to Specify
Ethnicity:	Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify
Preferred Language:	English Spanish Other
Hobbies:	Arts and Crafts Astronomy Baseball Basketball Boating Camping Computer games Cooking Dancing Diving Fishing Football Gardening Golf Hiking Horseback Riding Hunting Kid's activities Models Needlepoint None Paddling Painting Photography Piano Reading Roller Blading Running Sewing Skateboarding Skiing Soccer Softball Swimming Television Tennis Travel Video Games Woodworking Other
Referred By:	Other

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