New Patient Information Form

Name*

First Middle Last

Date*

Patient No.*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Birth Date*

Social Security #*

Home phone*

Work phone*

Cell phone*

Email*

Nickname:*

Your preferred contact:*

Home
Work
Cell
Email
Any

Are you:*

Minor
Married
Divorced
Widowed
Single
Separated

You or your parent’s employer*

Occupation*

Business Address*

Street Address City State / Province / Region ZIP / Postal Code

Spouse or parent’s name

Workplace*

Work phone*

If you are a student, name of school/college*

City*

State*

Whom may we thank for referring you to us?*

Person to contact in case of emergency*

Phone #*

RESPONSIBLE PARTY

Name of person responsible for this account*

Birth Date*

Relationship to patient*

Phone*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Name of employer

Work phone

FAMILY HISTORY

Please note any family history (parents, grandparents, siblings, children, living or deceased) for the following conditions and list the relationship of the family member to you:*

Other:

MEDICAL HISTORY

Do you have any allergies to medications?*

No
Yes

If yes, please explain:

List any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies):*

List all major injuries, surgeries and/or hospitalization you have had:*

List any of the following that you have had: crossed eyes, lazy eye, drooping eyelid, prominent eyes, glaucoma, retinal disease, cataracts, eye infections or eye injury?*

Are you pregnant or nursing?*

Yes
No

Visual correction:*

Contact Lesnes
Eyeglasses

How old is current pair of lenses?*

How old are your eyeglasses?*

Type of contact lenses?*

Rigid
Soft
Extended Wear
Other

Are they comfortable?*

Yes
No

Would you like new contact lenses today?*

Yes
No

Would you like new glasses today?*

Yes
No

SOCIAL HISTORY

This information is kept strictly confidential. However, if you prefer to discuss this directly with the doctor please check the following box. 

Do you drive?*

Yes
No

If yes, do you have visual difficulty when driving?*

Yes
No

If yes, please describe:

Do you or have you used tobacco products?*

Yes
No

If yes, type/amount/how long:

Do you drink alcohol?*

Yes
No

If yes, type/amount/how long:

Do you or have you used illegal drugs?*

Yes
No

If yes, type/amount/how long:

Have you ever been exposed to or infected with:*

Gonorrhea
Hepatitis
HIV
Syphilis
Chlamydia
None

What hobbies or sports do you participate in?

Do you work at a computer or video display terminal?*

REVIEW OF SYSTEMS

Do you currently, or have you ever had any problems in the following systems: (If YES, please explain)

Constitutional: (fever, weight loss / gain)*

Yes
No

If yes, explain:

Integumentary: (skin)*

Yes
No

If yes, explain:

Neurological: (headaches, migraines, seizures)*

Yes
No

Eyes: Loss of Vision*

Yes
N0

If yes, explain:

Eyes: Blurred Vision*

Yes
No

If yes, explain:

Eyes: Dryness / Burning / Sandy or Gritty Feeling*

Yes
No

If yes, explain:

Eyes: Mucous Discharge*

Yes
No

If yes, explain:

Eyes: Redness*

Yes
No

If yes, explain:

Eyes: Itching*

Yes
No

If yes, explain:

Eye Pain / Foreign Body Sensation*

Yes
No

If yes, explain:

Eyes: Excess Tearing / Watering*

Yes
No

If yes, explain:

Eyes: Glare / Light Sensitivity*

Yes
No

If yes, explain:

Eyes: Flashes / Halos / Double Vision*

Yes
No

If yes, explain:

Ears, Nose, Throat, Mouth:*

Yes
No

If yes, explain:

Respiratory: (asthma, chronic bronchitis, emphysema)*

Yes
No

If yes, explain:

Vascular/Cardiovascular: (i.e. high blood pressure, diabetes)*

Yes
No

If yes, explain:

Gastrointestinal: (diarrhea, constipation*

Yes
No

If yes, explain:

Genitourinary: (genitals, kidney, bladder)*

Yes
No

If yes, explain:

Bones / Joints / Muscles: (arthritis, muscle or joint pain)*

Yes
No

If yes, explain:

Lymphatic / Hematologic: (anemia, bleeding problems)*

Yes
No

If yes, explain:

Endocrine: (thyroid / other gland)*

Yes
No

If yes, explain:

Allergic / Immunologic:*

Yes
No

If yes, explain:

Psychiatric:*

Yes
No

If yes, explain:

I certify that I have read and answered the above questions to the best of my knowledge. I authorize the eye doctor to release any information including the diagnosis and records of any treatment or examination rendered to me or my child during the period of such eyecare to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the eye doctor or Vision Care Consultants any insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I acknowledge that I have received a notice of privacy from Vision Care Consultants.

PATIENT’S SIGNATURE*

Date*

DOCTOR’S SIGNATURE

Date

New Patient Information Form

PATIENT INFORMATION

RESPONSIBLE PARTY

FAMILY HISTORY

MEDICAL HISTORY

SOCIAL HISTORY

REVIEW OF SYSTEMS

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