New Patient Welcome Form

Mr.   Mrs.   Ms. 
 Other:    
Preferred Pronouns:He/Him   She/Her   They/Them                  

Preferred Name   First Name      

Date of birth:   Date   SSN (if applicable):   Type a label   

Texting?   Yes   No      

EMERGENCY CONTACT
First Name   Last Name   Phone:   Area Code   Phone Number 
Relationship:   Type a label      

VISION INSURANCE(if applicable)
  Please Select EyeMed (Blue View Vision, Cigna Vision) VSP (Delta, Guardian)   
 ID#:   Type a label      

Primary Insured:   First Name   Last Name     
Relationship to Insured:    Please Select Self Spouse Child Parent Other       
Date of Birth   

MEDICAL INSURANCE (if applicable)
    Please Select Anthem Blue Cross/Blue Shield Aetna Aetna Medicare Advantage Blue Cross/Blue Shield Medicare Advantage Connecticare Connecticare Medicare Advantage Cigna Harvard Pilgrim Health Care Pequot Medicare (Traditional) Medicaid Tricare Tricare for Life United Healthcare United Healthcare/AARP Supplement   
 ID#:      

Primary Insured:   First Name   Last Name     
Relationship to Insured:    Please Select Self Spouse Child Parent Other       
Date of Birth   

Other Insurance:   Type a label  
ID#:   Type a label   

Primary Care Physician   First Name   Last Name   
Clinic Name:   Type a label  
Other Clinic or Dr. to send exam notes to:   Type a label  

PREFERRED PHARMACY
Pharmacy Name:   Type a label   Town/City:   Type a label   

HEALTH HISTORY
Main Reason for Today's Exam:      Last Eye Exam:   Date
Last Physical Exam:   Date    
Are you pregnant or nursing?      YES   NO           
Past or Current Head/Eye Injuries or Surgeries:      
Current Medications (attach list if needed):      
Current Eye Drops:      
Allergies/Sensitivities to Medications:      
Other Allergies:      

SOCIAL HISTORY
Current Occupation:      Years:      
Employer:      
Do you Drive?    YES   NO        Drink Alcohol?      YES   NO         
Smoke Cigarettes?         YES   NO      

MEDICAL HISTORY
Have you been diagnosed with.....
High blood pressure?        YES   NO       
Diabetes?           YES   NO        
High cholesterol?        YES   NO           
HIV or AIDS?          YES   NO         
Arthritis?         YES   NO         
Asthma?           YES   NO      
COPD or lung problems?   YES   NO      
Thyroid Condition?            YES   NO      
History of stroke?          YES   NO       
Use a CPAP machine?     YES   NO              
Other? Please list           
    

FAMILY HISTORY
Unknown          If Yes, Who?
Macular Degeneration    YES   NO                  
Glaucoma      YES   NO                   
Color Blindness     YES   NO                    
Blindness    YES   NO                  
Diabetes     YES   NO                
Cancer      YES   NO                 
High Blood Pressure    YES   NO                 
Thyroid     YES   NO                
 Other? Please list           
    

GLASSES HISTORY
Have you ever worn glasses?     YES   NO              
Do you currently wear glasses?         YES   NO               
If yes, what type of glasses worn?   Distance   Reading   Bifocals (lined)   Progressives         
Have you ever worn contact lenses?      YES   NO            
Do you currently wear contact lenses?   YES   NO      
If yes, what brand/type of contact lenses?      

Any additional information you would like us to know:   Type a label