New Patient Form "*" indicates required fields General InformationThis field is hidden when viewing the formNames* First Middle Last First name*Middle NameLast Name*Preferred NameAddress* Street Address City State / Province / Region ZIP / Postal Code Gender* Male Female Date Of Birth* MM slash DD slash YYYY Age*Home PhoneWork PhoneCell Phone*Email* Preferred Office*New UlmSpringfieldWasecaContact InformationPreferred Contact Method* Home Phone Work Phone Cell Phone Email Social Security Number*Primary Languague*EnglishSpanishOtherOther LanguagueRace*AmericanIndianAsianBlackWhiteOtherOther RaceEthnicity*Not Hispanic/LatinoHispanic/LatinoUnknownEmployerSpouse’s nameResponsible PartyResponsible party* Self Other Relationship to you* Parent Guardian This field is hidden when viewing the formRelationship to youNames* First Last Responsible Party Date of Birth* MM slash DD slash YYYY Account ResponsibleIf other, provide information for whom should be billed.Address Of Responsible* Street Address City State / Province / Region ZIP / Postal Code Alternate ContactAlternate Contact First Last RelationshipHome numberCell PhoneWork NumberEmergency Contact Yes No How did you hear about us? I'm a regular patient Referred By Newspaper Website/Google Billboard Radio Other OtherReferal First Last Marital Status*MarriedSingleDivorcedOccupation*Date of Last Medical Exam* MM slash DD slash YYYY Primary Physician/Clinic*Date of Last Eye Exam* MM slash DD slash YYYY Eye Doctor’s Name/Clinic*Case History/Reason for VisitDo you wear glasses?*NoYesDo you wear glasses fulltime?NoYesIf not fulltime, when do you wear them?Do you wear contact lenses?NoYesWhat type of contacts?Are you having problems with your contacts?NoYesHow many hours a day do you wear your contact lenses?Hours per dayDo you sleep in your contact lenses?NoYesHow often do you wear contacts?Do you have a spare pair/backup pair of glasses?NoYesDo you have sunglasses?NoYesDo you have computer glasses?NoYesHave you had any eye injuries?NoYesWhich eye?RightLeftBothHave you had any eye surgeries?NoYesWhy?Have you used eye medication?NoYesWhy?Are you currently pregnant or nursing?NoYesN/AHave you ever been diagnosed with?Have you ever been diagnosed with? Cataracts Glaucoma Macular Degeneration Blindness Keratoconus Lazy Eye Poor Color Vision Retinal Disease What are your visual symptoms?What are your visual symptoms? Blurred Vision/Distance Blurred Vision/Near Double Vision Eye Strain Eye Infections Eye Pain/Soreness Tired Eyes Burning Eyes Itchy Eyes Dry Eyes Red Eyes Watery Eyes Wandering Eye Mucus Discharge Floaters or Spots See Flashes See Halos Poor Night Vision Poor Color Vision Droopy Lid Headaches Migraine Headaches Loss of Vision Crossed Eyes Light Sensitive Sandy/Gritty Feeling PERSONAL MEDICAL HISTORYCardiovascular None Hypertension Stroke Heart Disease Vascular Disease Other Endocrine None Non-insulin Dependent Diabetes Insulin Dependent Diabetes Thyroid Problem Hormonal Dysfunction Other Respiratory None Asthma Bronchitis Emphysema COPD Other Other CardiovascularOther EndocrineOther RespiratoryOcular None Glaucoma Macular Degeneration Detached Retina Other Neurological None Multiple Sclerosis Epilepsy Cerebral Palsy Tumor Other Constitutional None Cancer Trauma/Large Volume Blood Loss Developmental Disability Other Other OcularOther NeurologicalOther ConstitutionalPsychiatric None ADHD Depression Schizophrenia Other Musculoskeletal None Osteoarthritis Fibromyalgia Muscular Dystrophy Ankylosing Spondylitis Other Immunologic None AIDS or HIV Rheumatoid Arthritis Lupus Neurofibromatosis Other Other PsychiatricOther MusculoskeletalOther ImmunologicGastrointestinal None Crohn’s Colitis Other Hematological None Anemia Leukemia Other Ear/Nose/Throat None Hearing Loss Upper Respiratory Infection Other Other GastrointestinalOther HematologicalOther Ear/Nose/ThroatDermatologic None Eczema Rosacea Psoriasis Other Other DermatologicAlcohol UseNoYesAmount of alcohol useTobacco UseNoYesAmount of tobacco useAllergiesNoYesPlease list your allergiesDescribe your allergies/environment and drugs used.Please list physical reaction(s) to above allergiesPlease list all medications/drugs you are currently taking (including herbal) Add RemoveFamily History: Has anyone in your family (grandparents, parents, siblings, children, living or deceased) been diagnosed with the following diseases/conditions?Untitled Retinal Detachment High Blood Pressure Diabetes Cancer Heart Disease Thyroid Disease Blindness: Cataracts Crossed Eyes Macular Degeneration Retinal Disease: EmailThis field is for validation purposes and should be left unchanged.
