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:
*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. Ballantyne, Jordan Dr. McConkie	Misc/Guardian

Billing Information

Is The Billing Address the Same as above - If not please fill out the information below?

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

Nickname:
Last Eye Dr. Seen:
How long ago?
Who is your primary care physician?:
Primary Care Physician City:
Primary Care Physician State:
Primary Care Physician Phone:
Primary Care Physician Fax:
Approx date of last visit to your physician:
What was the reason for that visit?:
Race:	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Patient Declined to Specify Other
Ethnicity:	Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Other
Preferred Language:	English Spanish French Patient Declined to Specify Other

List all the medications you are currently taking, including over the counter meds: No current medications


List your allergies (if any). Include allergies to medications: No known drug allergies


NOTES:


Social History

Occupation:
Hobbies:
Describe your amount and frequency of alcohol consumption (if any):
Do you use marijuana or recreational drugs? If so, list them here:
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

Do you have any infections diseases (including STDs)? Example: Gonorrhea, Syphilis, Hepatitis, HIV, Tuberculosis. If so, list them here:

Are you interested in Contact Lenses?	No Yes Maybe Other
Are you interested in LASIK refractive surgery?	No Yes Maybe Other
Are you Pregnant or Nursing?	No Yes Unsure Other

PATIENT OCULAR HISTORY:

List any eye drops that you take including over the counter drops (unless you already listed them in the medication section):


Please list current or past eye disorders including: crossed eyes, lazy eye, drooping eyelid, glaucoma, cataracts, macular degeneration, retinal detachment, eye infection, eye injury:

Review of Systems

REVIEW OF SYSTEMS: Do you currently, or have you ever had, any problems in the following areas?

CONSTITUTIONAL (Fever, Weight Loss/Gain):	No Yes Other	If "yes" please explain:
INTEGUMENTARY (Skin):	No Yes Other	If "yes" please explain:
NEUROLOGICAL (Headaches, Migraines, Seizures):	No Yes Other	If "yes" please explain:
EYES (Loss of side vision, double vision, dryness, irritation, flashes and floaters):	No Yes Other	If "yes" please explain:
ENDOCRINE (Hyperthyroid, Hypithyroid, Hashimoto's, Grave's disease, Myasthenia Gravis):	No Yes Other	If "yes" please explain:
EAR, NOSE, MOUTH, THROAT (Allergies/hay fever, sinus congestion):	No Yes Other	If "yes" please explain:
RESPIRATORY (Asthma, chronic bronchitis, COPD):	No Yes Other	If "yes" please explain:
CARDIOVASCULAR (Diabetes, heart pain, high blood pressure, heart attack/stroke, high cholesterol):	No Yes Other	If "yes" please explain:
BONES/JOINTS/MUSCLES (Arthritis, muscle/joint pain, Rheumatoid Arthritis, Lupus, Sjogren's):	No Yes Other	If "yes" please explain:
BEHAVIORAL HEALTH (Anxiety, depression, mood disorder, ADHD):	No Yes Other	If "yes" please explain:

Use the drop down menus below to indicate if any of your family members have any of the following conditions:

Crossed / Lazy Eye	None Parent Sibling Relative Other
Glaucoma	None Parent Sibling Relative Other
Macular Degeneration	None Parent Sibling Relative Other
Retinal Detachment	None Parent Sibling Relative Other
Arthritis	None Parent Sibling Relative Other
Cancer	None Parent Sibling Relative Other
Diabetes	None Parent Sibling Relative Other
Heart Attack / Stroke	None Parent Sibling Relative Other
High Blood Pressure	None Parent Sibling Relative Other
Thyroid Disease	None Parent Sibling Relative Other

Notes-- you may tell us anything else about your eye or health history here:

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