New Patient Form
-Daphne-
We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions we will be glad to help you.
--*required--
PATIENT INFORMATION
Home Phone
*
Cell Phone
Soc. Sec. #
Patient Last Name
Patient First Name
Initial
Address
City
State
Zip
Email
*
Sex:
M
F
Age:
Birthdate:
Married
Widowed
Single
Separated
Divorced
Occupation:
Patient Employed by:
Business Address:
Business Phone:
Whom may we thank for referring you?
What is your reason for visit?
Last Exam Date:
INSURANCE & RESPONSIBILE PARTY INFORMATION
Person responsible for account?
(first name, Initial, last name)
Relationship to Patient:
Date of Birth:
Soc. Sec. #:
Address(if different from patient)
City
State
Zip
Person Responsible Employed by
Occupation
Business Address
Phone
Insurance Co.
Contract #
Group #
MEDICAL HISTORY
Allergies
Choose One
Yes
No
Asthma
Choose One
Yes
No
Skin Disorders
Choose One
Yes
No
Eye Diseases
Choose One
Yes
No
Eye Injury
Choose One
Yes
No
Eye Surgery
Choose One
Yes
No
Lazy Eye
Choose One
Yes
No
Cataracts
Choose One
Yes
No
Glaucoma
Choose One
Yes
No
Macular Degeneration
Choose One
Yes
No
Arthritis
Choose One
Yes
No
Cancer
Choose One
Yes
No
Diabetes
Choose One
Yes
No
Heart Disease
Choose One
Yes
No
High Blood Pressure
Choose One
Yes
No
Nerves
Choose One
Yes
No
Pregnant
Choose One
Yes
No
DO YOU...
Work at a computer for long periods?
Choose One
Yes
No
Have more than one pair of glasses?
Choose One
Yes
No
Want information on thinner, lighter glasses?
Choose One
Yes
No
Have problems with glare or reflection, when driving at night?
Choose One
Yes
No
Have prescription sunglasses?
Choose One
Yes
No
Do you wear bifocals?
Choose One
Yes
No
Have family members in need of eyecare?
Choose One
Yes
No
Have you ever worn / are you currently wearing contacts? Yes or No:
Are you interested in contact lenses? Yes or No:
Have you ever considered color contacts?Yes or No:
DO YOU EXPERIENCE...
Burning
Choose One
Yes
No
Itchiness
Choose One
Yes
No
Tearing
Choose One
Yes
No
Dryness
Choose One
Yes
No
Eye Strain
Choose One
Yes
No
Glare or Reflection
Choose One
Yes
No
Uncomfortable contacts
Choose One
Yes
No
Trouble working up close
Choose One
Yes
No
Spots
Choose One
Yes
No
Soreness
Choose One
Yes
No
Flashes of light
Choose One
Yes
No
Headaches
Choose One
Yes
No
Redness
Choose One
Yes
No
Double Vision
Choose One
Yes
No
Uncomfortable glasses
Choose One
Yes
No
Sudden loss of vision? Yes or No:
Sensitivity to light
Choose One
Yes
No
Fainting or Dizziness? Yes or No:
Blurry distance vision
Choose One
Yes
No
Gritty feeling of eyes? yes or No:
Trouble seeing at night
Choose One
Yes
No
Trouble reading or learning? yes or No:
CURRENT MEDICATIONS (Rx or Over the Counter)
Leave BLANK if none
Antihistamines?
High Blood Pressure?
Oral Contraceptives?
Blood Sugar?
Eye Drops?
Other?
Are you allergic to any medicine?
Name of your physician?
FAMILY MEDICAL HISTORY
Print the family members relationship. Leave BLANK if none.
Macular Degeneration?
Cataracts?
Glaucome?
Diabetes?
Heart Disease?
Other?