New Patient Form

Preferred Method of Contact Phone Call Text E-mail

Marital status Single Married Widowed

Do you have any allergies to medications Yes No

Are you pregnant and/or nursing? Yes No

Do you wear glasses? Yes No

Do you wear contact lenses? Yes No

Type of contact lenses: Rigid Soft Extended Wear

Are they comfortable? Yes No

Cataract Parents Grandparents Siblings Children

Blindness Parents Grandparents Siblings Children

Crossed Eyes Parents Grandparents Siblings Children

Glaucoma Parents Grandparents Siblings Children

Macular Degeneration Parents Grandparents Siblings Children

Retinal Detachment/Disease Parents Grandparents Siblings Children

Arthritis Parents Grandparents Siblings Children

Cancer Parents Grandparents Siblings Children

Diabetes Parents Grandparents Siblings Children

High Blood Pressure Parents Grandparents Siblings Children

Heart Disease Parents Grandparents Siblings Children

Kidney Disease Parents Grandparents Siblings Children

Lupus Parents Grandparents Siblings Children

Thyroid Disease Parents Grandparents Siblings Children

Do you drive? Yes No

If yes, do you have visual difficulty when driving? Yes No

Do you use tobacco products? Yes No

Do you use drink alcohol? Yes No

Do you use illegal drugs? Yes No

Have you ever been exposed to or infected with Gonorrhea Hepatitis HIV Syphilis

CONSTITUTIONAL Fever, Weight Loss/Gain None

INTEGUMENTARY (Skin) Yes No

EYES Loss of Vision Blurred Vision Distorted Vision/Halos Loss of Side Vision Double Vision Dryness Mucous Discharge Redness Sandy or Gritty Feeling Itching Burning Foreign Body Sensation Excess Tearing/Watering Glare/Light Sensitivity Eye Pain or Soreness Chronic Infection of Eye or Lid Sties or Chalazion Flashes/Floaters in Vision Tired Eyes

ENDOCRINE Thyroid/Other Glands None

EAR, NOSE, MOUTH, THORAT Allergies/Hay Fever Sinus Congestion Chronic Cough

RESPIRATORY Asthma Chronic Bronchitis Emphysema

VASCULAR/CARDIOVASCULAR Diabetes Heart Pain High Blood Pressure Vascular Disease

GASTROINTESTINAL Diarrhea Constipation

GENITOURINARY Genitals/Kidney/Bladder None

BONES/JOINTS/MUSCLES Rheumatoid Arthritis Muscle Pain Joint Pain

LYMPHATIC/HEMATOLGOIC Anemia Bleeding Problems

ALLERGIC IMMUNOLOGIC Yes No

PSYCHIATRIC Yes No