Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.New Patient Information Name *FirstLastEmailAddress *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome # *Cell # Work #Date of Birth *Age *Family Physician *Referring Physician: *Local Pharmacy: *Local Pharmacy Address:Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMail Order Pharmacy:Emergency Contact: *Phone *Gender *MaleFemaleRace *WhiteAsianBlack/African AmericanSpanish/Hispanic OriginAmerican IndianNative Hawaiian/Other Pacific IslanderOtherPreferred Language *Is patient enrolled in Hospice? *YesNoIf yes, Medicare ID #:Primary Medical InsuranceSubscriberID No.DOBGroup ID #If seen by us for a worker's compensation injury: what Name use: CompanyHR ContactPhone In order to comply with federal regulations regarding your privacy in our office, we ask that you complete the following questions: How can we communicate APPOINTMENT information?Home PhoneCell PhoneWork PhoneWith a Specific PersonUS MailE-mailHow can we communicate MEDICAL information?Home PhoneCell PhoneWork PhoneWith a Specific PersonUS MailE-mailPlease provide the name and relationship of the specific person(s) with whom we may share patient information (medical, billing, and appointments) about you. This information will only expire when requested by the patient. NameFirstLastRelationshipPhoneNameFirstLastRelationshipPhoneNameFirstLastRelationshipPhoneAllergies to Medications? *HeightWeightLast Hemoglobin AICEmployerOccupationJob Physical Function (i.e. lifting, bending, etc.)Reason for Today's Visit *CataractsDry EyesDriving Difficulty (day/night)Diabetic ExamFlashesDecreased VisionIncreased VisionFloatersOtherWould you like to be checked for a new eyeglass prescription today? *YesNoIs your current problem injury related? *YesNoIf yes, date of injury:Cause of InjuryWork AccidentHome AccidentAuto AccidentSports Related ActivityOtherHistory of Present Problems/Illness (please describe your current problem)Medical History (please check yes or no) Heart Disease *YesNoCancer *YesNoIf yes, what type?Mitral Valve Prolapse *YesNoRheumatoid Arthritis/Lupus *YesNoProblem with Anestheia *YesNoUlcers/Stomach Problems *YesNoHemophilia/Bleeding Problems/Anemia *YesNoNervous/Mental Disorder/Depression *YesNoUnusual Childhood Disease (measles, mumps, etc.) *YesNoBlood Clot/DVT/Pulmonary Emulsion *YesNoDiabetes *YesNoThyroid Disease *YesNoHigh Blood Pressure *YesNoKidney Disease *YesNoHepatitis/Liver Disease *YesNoHIV/AIDS *YesNoEpilepsy/Seizures *YesNoCholesterol *YesNoVenereal Disease *YesNoAsthma/Respiratory Disease/TB *YesNoOther:Past Medical Surgical History (list types of surgery) Past Eye Problems/DiseasesPast Eye Surgical History (list types of surgery)Family Eye History (check all that apply)GlaucomaDiabetesMacular DegenerationCorneal ProblemsCataractAdoptedUnknownDo you drive?YesNoIf so;Daytime onlyBoth day and nighttime drivingSocial HistoryMarriedSingleDivorcedWidowDomestic PartnerCivil UnionLives AloneAlcohol Use1-2 Drinks/Day1-2 Drinks/Week3+ Drinks/DayRarely DrinksNever DrinksTobacco UseCurrent SmokerChew/snuffFormer SmokerNever SmokedIf you smoke, for how many years and how many packs per day?Please list recreational drug use:THE ABOVE INFORMATION IS CORRECT AND WAS FILLED OUT TO THE BEST OF MY ABILITY: Electronic signature (type name) *(Parent signature if patient is a minor) Date *Submit