New Patient Form Date: Date Format: MM slash DD slash YYYY Patient Name: First Last DOB: Date Format: MM slash DD slash YYYY Address: Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email: Phone:Cell Phone:Date of Last Eye Exam: Date Format: MM slash DD slash YYYY Social Security Number:Primary Physician:Date of Last Medical Exam: Date Format: MM slash DD slash YYYY Occupation:Hobbies:Are you currently pregnant or nursing?YesNoN/AGlassesDo you wear glasses?YesNoAre they for Near Vision?YesNoAre they for Distance Vision?YesNoAny problems with Near Vision with our without glasses?YesNoAny problems with Distance Vision with our without glasses?YesNoContact LensesDo You Wear Contacts?YesNoWhat type of Lenses do you wear? Soft Disposable Dailies Extended Wear Bifocal Gas Permeable Hard Lenses Are you happy with your current lenses:YesNoWearing Schedule:DailyOvernightSolution Used:VISUAL CONCERNS:HEADACHES:YesNoHow long have you had them?PAIN IN EYE:YesNoPlease specify: Right Left Both Where is Pain Located:How Long?DOUBLE VISION:YesNoSPOTS:YesNoFLASHES:YesNoDRY EYES:YesNoBURNING EYES:YesNoOTHER:YesNoIf other, please specify:PRIOR DIAGNOSES OR PROBLEMS:Personal Medical History (Review of Systems):Please check if any of the following applies to you past or present and list all medications below. If you have none of these conditions, please check NONE.Cardiovascular: None High Blood Pressure High Cholesterol Heart Disease Vascular Disease Stroke Other If other, please specify:Endocrine: None Type 2 Diabetes Type 1 Diabetes Thyroid Problem Hormonal Dysfunction Other If other, please specify:Constitutional: None Cancer Trauma/Large Volume Blood Loss Developmental Disability Other If other, please specify:If cancer, please specify the type:Respiratory: None Asthma Bronchitis Emphysemia COPD Other If other, please specify:Neurological: None Multiple Sclerosis Epilepsy/Seizure Disorder Cerebral Palsy Tumor Migraines/Headache Disorder Other If other, please specify:Musculoskeletal: None Arthritis Fibromyalgia Muscular Dystrophy Anklosing Spondylitis Other If other, please specify:Immunological: None AIDS or HIV Lupus Neurological Other If other, please specify:Heomatological: None Anemia Leukemia Other If other, please specify:Gastrointestinal: None Chrone's Colitis Other If other, please specify:Ear/Nose/Throat: None Hearing Loss Upper Respiratory Infection Other If other, please specify:Dermatologic: None Eczema Rosacea Psoriasis Skin Cancer Other If other, please specify:Allergies: None Please List Allergies:Drug/Medication:Environmental:Other: Alcohol UseYesNoAmount:Tobacco UseCurrentPastNeverAmount:Number of Years:Please list any medications that you are taking:(Including vitamin, herbs, supplements and over the counter) FAMILY HISTORY:Has anyone in your immediate family (grandparents, parents, siblings, children, living or deceased) been diagnosed with:Lupus:YesNoRelationship:High Blood Pressure:YesNoRelationship:Diabetes:YesNoRelationship:Heart Disease:YesNoRelationship:Thyroid Disease:YesNoRelationship:Cancer:YesNoRelationship:If cancer, please specify the type:Blindness:YesNoRelationship:Cataracts:YesNoRelationship:Glaucoma:YesNoRelationship:Crossed Eyes:YesNoRelationship:Macular Degeneration:YesNoRelationship:Retinal Detachment:YesNoRelationship:Other:YesNoRelationship:If other, please specify:Patient SignatureDate Date Format: MM slash DD slash YYYY