New Patient Form Date: MM slash DD slash YYYY Patient Name: First Last DOB: MM slash DD slash YYYY Address: Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email: Phone:Cell Phone:Date of Last Eye Exam: MM slash DD slash YYYY Social Security Number: Primary Physician: Date of Last Medical Exam: MM slash DD slash YYYY Occupation: Hobbies: Are you currently pregnant or nursing? Yes No N/A GlassesDo you wear glasses? Yes No Are they for Near Vision? Yes No Are they for Distance Vision? Yes No Any problems with Near Vision with our without glasses? Yes No Any problems with Distance Vision with our without glasses? Yes No Contact LensesDo You Wear Contacts? Yes No What type of Lenses do you wear? Soft Disposable Dailies Extended Wear Bifocal Gas Permeable Hard Lenses Are you happy with your current lenses: Yes No Wearing Schedule: Daily Overnight Solution Used: VISUAL CONCERNS:HEADACHES: Yes No How long have you had them? PAIN IN EYE: Yes No Please specify: Right Left Both Where is Pain Located: How Long? DOUBLE VISION: Yes No SPOTS: Yes No FLASHES: Yes No DRY EYES: Yes No BURNING EYES: Yes No OTHER: Yes No If 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 Use Yes No Amount: Tobacco Use Current Past Never Amount: 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: Yes No Relationship: High Blood Pressure: Yes No Relationship: Diabetes: Yes No Relationship: Heart Disease: Yes No Relationship: Thyroid Disease: Yes No Relationship: Cancer: Yes No Relationship: If cancer, please specify the type: Blindness: Yes No Relationship: Cataracts: Yes No Relationship: Glaucoma: Yes No Relationship: Crossed Eyes: Yes No Relationship: Macular Degeneration: Yes No Relationship: Retinal Detachment: Yes No Relationship: Other: Yes No Relationship: If other, please specify: Patient SignatureDate MM slash DD slash YYYY