New Patient Form New Patient Form Step 1 of 2 50% Patient InformationName* First Last Birthdate* Last Four of Social Securty Number* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home PhoneCell PhoneEmail Whom can we thank for referring you to our practice? Name of Primary Care Doctor When was your last physical exam? When was your last eye exam? Insurance InformationVision Savings Plan Subscriber ID Number Subscriber's Name Date of Birth Relationship to Patient Self Spouse Parent Medical Insurance Subscriber ID Numbder Subscriber's Name Date of Birth Relationship to Patient Self Spouse Parent Eye Health InformationDo You Wear Any Vision Correction? Glasses Soft Contacts Rigid Contacts Prescription Sunglasses *Please bring all glasses and contact lens boxes to exam.Do You Suffer From Any Eye Problems? Amblyopia (Lazy Eye) Blurred Vision at Distance Blurred Vision at Near Burning Double Vision Drooping Eyelid(s) Dryness Eye Pain and/or Soreness Flashes of Light Floaters or Spots Fluctuating Vision Foreign Body Sensation Glare/Light Sensitivity Haloes Infection of Eye or Lid Itching Loss of Side Vision Mucous Discharge Redness Sandy or Gritty Feeling Strabismus (Crossed Eye) Tired Eyes Watery Eyes *Please check all boxes that apply.Medical HistoryList All Medical Conditions, Injuries, and Surgeries *Diabetes, High Blood Pressure, Elevated Cholesterol, etc...List All Current and Past Eye Diseases, Injuries, and Surgeries List All Medications You Are CurrentlyTaking *Include Eye DropsList All Medication Allergies Family HistoryList Any Major Medical Conditions That Run in Your Family. *Diabetes, Heart Disease, Cancer, etc...List Any Eye Conditions That Run in The Family. *Glaucoma, Macular Degeneration, Blindness, etc...Any Current Medical Conditions/Symptoms? Chronic fever, unexpected weight loss/gain, fatigue Ear/Nose/Throat problems (eg. Hearing Loss, SInus Problems, Sore Throat) Neurological Problems (eg. Numbness, Weakness, Headaches, "Blackouts") Psychiatric Problems (eg. Depression, Anxiety) Heart Problems (eg. Chest Pain, Irregular Heartbeat, Swelling of Feet, Cold Hands or Feet) Respiratory Problems (eg. Shortness of Breath, Wheezing, Coughing) Gastrointestinal Problems (eg. Heartburn, Abdominal Pain, Diarrhea, Vomiting) Musculoskeletal Problems (eg. Muscle Aches, Joint Pain, Swollen Joints) Skin Problems (eg. Rashes, Excessive Dryness, Growths or Lumps) Endocrine Problems (eg. Frequent Urination, Thirst, Feeling Hot or Cold All the Time) Blood/Lymph Problems (eg. Bruising, Weakness, Unusual Paleness, Swollen Glands) Immune Problems (eg. Frequent Infections, Allergic Reactions to Foods/Dust/Pollens) Social HistoryTobacco UseHow Often?EverydaySomedayQuit SmokingNeverUnknownAlcohol UseHow Often?DailyOccassionallyNeverOther Substance UseOther Substance Use?MarijuanaSmokeless TobaccoIllicit DrugsMarital StatusMarital StatusDivorcedLegally SeparatedMarriedSingleOtherAre you Pregnant or Nursing?Are you Pregnant or Nursing?YesNo