New Patient Information Form PATIENT INFORMATION Thank you for choosing Vision Care Consultants for your eye care needs. Please complete BOTH SIDES of this form in ink. If you have any questions or concerns, do not hesitate to ask for assistance. We will be happy to help. (Please Print) Name* First Middle Last Date* MM slash DD slash YYYY Patient No.* Address* Street Address City State / Province / Region ZIP / Postal Code Birth Date* MM slash DD slash YYYY 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 PARTYName of person responsible for this account* Birth Date* MM slash DD slash YYYY Relationship to patient* Phone*Address* Street Address City State / Province / Region ZIP / Postal Code Name of employer Work phone FAMILY HISTORYPlease 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:* Blindness Glaucoma Arthritis Heart Disease Lupus Cataract Macular degeneration Cancer High Blood Pressure Thyroid Disease Crossed eyes Retinal Disease Diabetes Kidney Disease Other: MEDICAL HISTORYDo 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 HISTORYThis 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 SYSTEMSDo 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* MM slash DD slash YYYY DOCTOR’S SIGNATUREDate MM slash DD slash YYYY Print this form