New Patient Form

Please complete the following form as thoroughly as possible. The information in this confidential case history form is critical to the evaluation of your vision and health.

Patient Information

Last*

First*

Street*

City*

State*

Zip Code*

Cell Phone*

Work Phone

Sex

MaleFemale

Date of Birth*

Last 4 digits of SSN of primary insured

Email Address*

Employer/School

Occupation/Grade

Spouse/Parent’s Name

Spouse/Parent’s Employer

Medical Insurance*

Blue Cross Blue Shield United Health Care Cigna Aetna Medicare Medicaid MediShare None Other

Vision Insurance*

VSP Spectra Davis Eyemed None Other

Upload Drivers License/Photo ID
File must be 2MB or less

Upload Insurance Card
File must be 2MB or less

How did you first hear about our office?*

Friend or RelativeInsurance ListFacebookInstagramAnother DoctorSaw Sign/BuildingOnline SearchNeigborhood WebpageOther

Medical History

Name of Family Physician

City

Date of Last Physical Check-Up

Height

Weight

Do you use

Cigarettes/TobaccoAlcoholOther Substances

Females

Are you pregnant?Are you nursing?

Are you allergic to any medications?*

Yes No

Current Medications (Rx or Over-The-Counter)

List name of medications including eye drops, vitamins, & birth control pills: dosages and frequency.

Non-eye related surgeries or hospitalizations

Have you ever been diagnosed or treated for the following health problems?

CancerDevelopmental DisabilityCongestive Heart FailureGoutHearing LossVascular DiseaseChronic SinusitisAsthmaEczemaDry MouthChronic BronchitisRosaceaMultiple SclerosisEmphysemaPsoriasisEpilepsySleep ApneaCold SoresCerebral PalsyCrohn'sShinglesStroke/CVAColitisType 1 DiabetesMigraineCeliac DiseaseType 2 DiabetesAutism Spectrum DisorderKidney DieseaseThyroid DysfunctionADHDSTDHormonal DysfunctionDepressionArthritisAnemiaAnxietyFibromyalgiaHigh CholesterolBipolar DisorderMuscular DystrophyLupusHigh Blood PressureAnkylosing SpondylitisSjogren's Syndrome

Eye History

Date of Last Eye Exam?*

By Whom?

Have you had any eye-related surgeries of any kind?

Yes No

Are you currently experiencing, have been diagnosed with, or treated for any of the following?

Blurry VisionBurningCataractsCorneal AbrasionsCrossed Eyes/Eye TurnEye InfectionsEye InjuryFlashes of LightFloaters/SpotsGlaucomaGrittinessHeadachesIritis/UveitisItchinessLazy Eye (Amblyopia)Macular DegenerationDry EyesRetinal DetachmentSunlight SensitivityTrouble Seeing at NightTearingRedOther