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NEW VISION OPTICAL
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New Patient Form
First name
*
Last name
*
Address
*
Phone
*
Email
*
Sex
*
Male
Female
Last Four of SSN
*
Birthday
*
Month
Day
Year
Employer
*
Position
*
Insurance Providor
ID Number
Referred By
Date of Last Eye Exam
Location of Last Eye Exam
Have you ever been examined at this office before?
Yes
No
Have you ever worn glasses?
Yes
No
If so, how are they used?
Distance
Near
Constant Wear
Have you ever worn contacts?
Yes
No
Do you wear contacts now?
Yes
No
How old are your contacts?
What type/brand of contacts?
Reason for today's visit
*
General Check-Up
Pain in Eyes
Poor Night Vision
Lost or Broken Glasses
Seeing Spots
Contact Lenses
Blurred Distance Vision
Blurred Near Vision
Eyes Burn or Itch
Headaches
Problem with Current Contacts
Color Vision Problems
Other
List all medications that you are currently taking
*
Do you have any allergies?
*
Yes
No
Please List
Do you or any family members have diabetes?
*
Yes
No
Who?
Do you or any family members have glaucoma?
*
Yes
No
Who?
Do you or any family members have cataracts?
*
Yes
No
Who?
Do you or any family members have high blood pressure?
*
Yes
No
Who?
Do you or any family members have thyroid problems?
*
Yes
No
Who?
Do you have heart disease?
*
Yes
No
Do you have arthritis?
*
Yes
No
Do you have HIV/AIDS?
*
Yes
No
Are you pregnant?
*
Yes
No
Do you see double?
*
Yes
No
When?
Have you ever had an eye infection?
*
Yes
No
Have you ever had an eye injury?
*
Yes
No
Have you ever had an eye surgery?
*
Yes
No
We may need to instill drops to examine your eyes. These drops may cause some sensitivity to light and blurred vision. Do we have your permission for diagnostic drops to be used if needed?
*
Yes
No
Signature
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