New Patient Form
Legal Name
*
First Name
Last Name
Nickname
Sex Assigned At Birth*
*
Male
Female
Gender Identity
Male
Female
Non Binary
Pronouns
He/Him/His
She/Her/Hers
They/Them/Theirs
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email*
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
What is your contact preference?
*
Phone
Email
Text
Occupation
*
Employer
*
Guardian's Name (if minor)
Guardian's Employer (if minor)
Relationship
Do you have medical health insurance?
*
Yes
No
Vision Discount Plan
*
Vision Service Plan (VSP)
None
Other
Medical Insurance
*
Name of Primary Insured
*
Primary Insured Date of Birth
*
Primary Insured's Last Four Digits of SSN
*
Relationship to Patient
*
Whom may we thank for referring you to our office?
What brings you in today? (Please check all that apply)
Glasses
Contact Lenses
Dr. Requested Follow-Up
Eye Allergies
Eye Irritation
Eye Infection
Headaches
Flashes/Floaters
Lasik Consultation
Ocular Symptoms (Please check all that apply)
Burning
Dryness
Itching
Tearing
Redness
Eye Pain
Blurred Vision
Headaches
Foreign Body Sensation
Light Sensitivity
Flashes
Floaters
Double Vision
Headache/Migraine
Discharge
Loss of Vision
Patient's Ocular Health History (Please check all that apply)
Dry Eyes
Eye Injuries
Strabismus (Eye Turns)
Blindness
Cataracts
Glaucoma
Retinal Detachment
Keratoconus
Color Vision Problem
Amblyopia (Lazy Eye)
Macular Degeneration
Family's Ocular Health History (Please check all that apply)
Strabismus (Eye Turns)
Blindness
Cataracts
Glaucoma
Retinal Detachment
Keratoconus
Color Vision Problem
Amblyopia (Lazy Eye)
Macular Degeneration
Eye Injuries/Surgeries
Eye Medications/Drops
Patient Medical History
Full Name of Your Primary Care Physician
Constitutional (changes in weight, sleep)
Yes
No
Explanation of Problems
Ear, Nose, Throat
Yes
No
Explanation of Problems
Neurology (headaches, MS, tumors)
Yes
No
Explanation of Problems
Psychiatric (depression, anxiety, ADD, autism)
Yes
No
Explanation of Problems
Cardiovascular (heart disease, high blood pressure)
Yes
No
Explanation of Problems
Respiratory (asthma, emphysema)
Yes
No
Explanation of Problems
Gastrointestinal (ulcers, reflux, IBS)
Yes
No
Explanation of Problems
Genitourinary (genitals, kidneys, bladder)
Yes
No
Explanation of Problems
Bones/Joints/Muscles
Yes
No
Explanation of Problems
Skin Disorders (rosacea, lupus)
Yes
No
Explanation of Problems
Blood/Lymph
Yes
No
Explanation of Problems
Allergy (seasonal, foods, medications)
Yes
No
Explanation of Problems
Cancer
Yes
No
Explanation of Problems
Endocrine (diabetes, thyroid)
Yes
No
Last Hemoglobin A1C?
Full name of endocrinologist?
How frequently do you see your endocrinologist?
Currently Pregnant
Yes
No
Currently Nursing
Yes
No
List all medications, supplements, and over the counter medicine you take on a routine basis
Are you allergic to any medications?
Yes
No
List all medication allergies
Do you use tobacco products?
Yes
No
Type/Amount/How Long?
Do you drink alcohol?
Yes
No
Type/Amount/How Long?
Family Medical History
Family's Medical Health History (Please check all that apply)
Cancer
Diabetes
Hypertension
Thyroid Disorder
Autoimmune Disorder
Other relevant medical history in your immediate family?
*
Yes
No
Explanation of Problem
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