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 Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed Employer/School Name Primary Doctor No Doctor Assigned Dr. Strube, Eva Dr. Borden, Joe 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 New Insurance New Insurance New Insurance New Insurance New Insurance AARP Medicare Supplement Plan by United HEalthcare Advantek Aetna Anthem Avesis Beech Street Beta Health Vision Plan of Colorado Blue Cross Blue Shield CHAMPVA Cigna CNIC Health Solutions Cofinity Colorado Health Op Comp Benefits Coventry Eye Specialist EyeBenefits EyeMed GEHA Goldens Lyon's Club Government Employees Health Association Great West Humana Kaiser Medco Medicaid Medicare Met Life New Insurance New Insurance New Insurance Optum Health Spectra Pacificare PHCS Railroad Medicare Rocky Mountain Health Plans Rocky Mountain UFCW Samaritan Health Choice Secure Horizons Sun Life and Health Superior Vision TLC UMR/United Health Care United Health Care Student Resources United Healthcare United Healthcare AARP/Medicare VCPN (Humana) Vision Care Direct Vision Service Plan
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account:

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 New Insurance New Insurance New Insurance New Insurance New Insurance AARP Medicare Supplement Plan by United HEalthcare Advantek Aetna Anthem Avesis Beech Street Beta Health Vision Plan of Colorado Blue Cross Blue Shield CHAMPVA Cigna CNIC Health Solutions Cofinity Colorado Health Op Comp Benefits Coventry Eye Specialist EyeBenefits EyeMed GEHA Goldens Lyon's Club Government Employees Health Association Great West Humana Kaiser Medco Medicaid Medicare Met Life New Insurance New Insurance New Insurance Optum Health Spectra Pacificare PHCS Railroad Medicare Rocky Mountain Health Plans Rocky Mountain UFCW Samaritan Health Choice Secure Horizons Sun Life and Health Superior Vision TLC UMR/United Health Care United Health Care Student Resources United Healthcare United Healthcare AARP/Medicare VCPN (Humana) Vision Care Direct Vision Service Plan
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account:

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:

Patient History

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Patient Medical History

Grade or Occupation:

D.O.B

Insurance:

Date of Last Eye Exam:

Doctor's name:

New Patients: How did you hear of us?

Insurance Sign Website Advertising Phone Book Friend / Doctor/ Therapist

Referred By:

Former Patients: You come back because:

Good Service Holistic Care Convenience Thorough Exams Friendliness

Your Health

Any conditions you suffer from or are taking medicine for?

History:	Medications (including vitamins & supplements):

Allergies:	Are you using any drops in your eyes?

Sleep:

Well Fairly Well Not Enough Poorly Insomnia Other

How often do you exercise?

Nutrition: how many servings of fruit and vegetables do you eat daily?

One or Two Three Four or Five More than 5 Other

Health History

Your main vision problem(necessary for insurance to pay your bill)

Family history of poor vision. Nearsightedness Farsightedness Astigmatism Aging Eyes Red Eye Other

Please specify self, parent, siblings, grandparents, etc:

Glaucoma	Self Mom Dad Sister or Brother Grandparent Aunt, Uncle, or Cousin Other	Lazy eye/Amblyopia	Self Mom Dad Sister or Brother Grandparent Aunt, Uncle,or Cousin Other	Color Vision Defect	Self Mom Dad Sister or Brother Grandparent Aunt, Uncle, or Cousin Other
Arthritis	Self Mom Dad Sister or Brother Grandparent Aunt, Uncle, or Cousin Other	Cataracts	Self Mom Dad Sister or Brother Grandparent Aunt, Uncle, or Cousin Other	Blindness	Self Mom Dad Sister or Brothe Grandparent Aunt, Uncle, or Cousin Other
Retinal Problem	Self Mom Dad Sister or Brother Grandparent Aunt, Uncle, or Cousin Other	Cholesterol	Self Mom Dad Sister or Brother Grandparent Aunt, Uncle, or Cousin Other	Diabetes	Self Mom Dad Sister or Brother Grandparent Aunt, Uncle, or Cousin Other
Eye injury or surgery	Self Mom Dad Sister or Brother Grandparent Aut, Uncle, or Cousin Other	High Blood Pressure	Self Mom Dad Sister or Brother Grandparent Aunt, Uncle, or Cousin Other	Thyroid	Self Mom Dad Sister or Brother Grandparent Aunt, Uncle, or Cousin Other
Macular Degeneration	Yes Self Mom Dad Sister or Brother Grandparent Aunt, Uncle, or Cousin Other	Head injury / trauma	Self Mom Dad Sister or Brother Grandparent Aunt, Uncle, or Cousin Other	Wears glasses, contact lenses or other optical devices	Self Mom Dad Sister or Brother Grandparent Aunt, Uncle, or Cousin Other
Sinus Problems	Self Mom Dad Sister or Brother Grandparent Aunt, Uncle, or Cousin Other	Breathing problems	Self Mom Dad Sister or Brothe Grandparent Aunt, Uncle, or Cousin Other	Migraines	Self Mom Dad Sibling Grandparent Aunt, Uncle, or Cousin Other
Dry Eye	No Yes Other	Frequent styes	Self Mom Dad Sister or Brother Grandparent Aunt, Uncle, or Cousin Other	Musculoskeletal problems	Self Mom Dad Sister or Brother Grandparent Aunt, Uncle, or Cousin Other
Cancer	Self Mom Dad Sibling Grandparent Aunt, Uncle, or Cousin Other	Learning issue	Self Mom Dad Sibling Grandparent Aunt, Uncle, or Cousin Other	Asthma	Self Mom Dad Sister or Brother Grandparent Aunt, Uncle, or Cousin Other
Eyelid Droops	Self Mom Dad Sibling Grandparent Aunt, Uncle or Cousin Other	Seizures	Self Mom Dad Sibling Grandparent Aunt, Uncle or Cousin Other	Hormonal Issues	Self Mom Dad Sibling Grandparent Aunt, Uncle, or Cousin Other
Heart Disease	Self Mom Dad Sister or Brother Grandparent Aunt, Uncle, or Cousin Other	Lupus Erythematosis	Self Mom Dad Sibling Grandparent Aunt Uncle or Cousin Other	Ear / Nose / Throat problems	Self Mom Dad Sibling Grandparent Aunt, Uncle, or Cousin Other
Eye turns in / out	Self Mom Dad Sibling Grandparent Aunt, Uncle, or Cousin Other

COVD

COVD Quality of Life Checklist

Select the option which best represents the occurrence of each symptom.

Frequency: Never=0, Seldom= 1, Occas=2, Freq=3, Always=4

Catagory	Symptom	Frequency
A	Blur when looking at near	0 1 2 3 4
A	Headaches with near work	0 1 2 3 4
A	Sees worse at end of the day	0 1 2 3 4
A	Difficulty copying from the chalkboard	0 1 2 3 4
A	Avoids near work/reading	0 1 2 3 4
A	Holds head too close to the page	0 1 2 3 4
B	Has double vision	0 1 2 3 4
B	Words run together while reading	0 1 2 3 4
B	Eyes burn, eitch or seem watery	0 1 2 3 4
B	Falls asleep while reading	0 1 2 3 4
B	Closes one eye or tilts head while reading	0 1 2 3 4
OR	Dizzy or nauseous with near work	0 1 2 3 4
OR	Writes up or down hill	0 1 2 3 4
OR	Poor/inconsistent in sports	0 1 2 3 4
OR	Avoids sports/games	0 1 2 3 4
OR	Poor hand-eye coordination/poor handwritting	0 1 2 3 4
OR	Clumsy/knocks things over	0 1 2 3 4
OR	Car/motion sickness	0 1 2 3 4
OM	Skips or repeats lines when reading	0 1 2 3 4
OM	Misaligns digits/columns of numbers	0 1 2 3 4
P	Reading comprehension is poor	0 1 2 3 4
P	Trouble keeping attention on reading	0 1 2 3 4
P	Says "I can't" before trying	0 1 2 3 4
P	Does not use his/her time well	0 1 2 3 4
P	Does not make change well with money	0 1 2 3 4
P	Loses belongings/things	0 1 2 3 4
P	Forgetful/poor memory	0 1 2 3 4
ALL	Difficulty completing assignments on time	0 1 2 3 4
ALL	Does not make change well with money	0 1 2 3 4

Final Score

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