New Patient Information Form

NEW PATIENT INFORMATION

Patient's Name
Last Name, First Name, M.I.

Social Security # (000-00-0000)

Marital Staus
Single Married Widowed Divorced

Sex
M F

Birth Date

Physical Address

City, State, Zip Code

Home Phone # (000) 000-0000

Cell Phone # (000) 000-0000

Work Phone # (000) 000-0000

Patient's Employer

Occupation (Indicate if Student)

Texas Drivers License #

Person Responsible for Payment (If Different than Above Party)

Mailing, City, State, Zipe Code

Social Security # (000-00-0000)

Birth Date

Home Phone #

Work Phone #

Texas Driver's License

Relationship to Party

Primary Cardholder's Name

Date of Birth

Name of Insurance Plan

Insured's Name

Date Of Birth

Group #

ID #

ID # - Please enter your ID # again for accuracy

Providers Contact Phone #

Is your health plan a PPO or HMO?

Who referred you to our office?

Family Physician

Present Glasses- How old are they?

Do you wear Contacts?
Yes No

A very important part of your examination is for your doctor' to know your past medical and surgical history. Many eye problems are caused by systemic disease. Please carefully complete this portion of this form so your doctor can give you the best care possible.

Present Medications (Including Prescriptions):

List Medication Allergies, If Any:

General Medical:
Do you have the following?

Allergies	Herpies
Arthritis	High Blood Pressure
Asthma	Neurological Problems
Diabetes	Heart Disease
Epilepsy

Other:

OCULAR:
Have you had any of the following?

Cataratacts: Right Eye Left Eye

Glaucoma: Right Eye Left Eye

Muscle Imbalance (Crossed Eyed)

Lens Implants? When?

Right Eye Left Eye

Cornea Transplant? When?

Right Eye Left Eye

Social History:

Smoking?
Y N

How Much Smoking?

Alcohol?

Y N

How Much Alcohol?

Family History of Eye Problems:

Cataracts	Retinal Detachment
Glaucoma	Crossed Eyes

Macular (Retinal) Degernation