Please complete the information below and submit the form online. This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Patient Information

Name*

First Middle Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Number*

Please provide a telephone number, with area code, so we can contact you.

Cell Phone

Work Phone

Email Address

Please provide your email address.

Employer

Occupation

Date of Birth*

Social Security Number (last 4 digits only!)

Race/Ethnicity

Preferred Language

Sex

Female
Male

Who may we thank for referring you to our office?

Primary Insurance

Please bring all insurance cards with you to your appointment.

Insurance Company Name

Insurance Company Phone Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Insured's Name

First Last

Identification Number

Group Number

Insured's Date of Birth

Patient's Relation to Insured

Secondary Insurance

Do you have secondary insurance?

Yes
No

If you have coverage through another plan/organization, please fill in the details below.

Insurance Company Name

Insurance Company Phone Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Insured's Name

First Last

Identification Number

Group Number

Insured's Date of Birth

Pharmacy info

Enter in local and mail order pharmacy details

Date of Last Medical Exam

Name of Medical Doctor

Doctor's Phone Number

Name of Eye Doctor

Date of Last Eye Exam

Current Height

Current Weight

Spouse or Guardian (If Applicable)

Medical History

Do you have any allergies to medications?

No
Yes

If Yes, list medication(s) and reaction below:

List any medications you take including oral contraceptives, aspirin, OTC medicines, etc.:

Include Name of Medication, Dosage, Frequency Taken

List all major injuries, surgeries and/or hospitalizations you have had:

Including any Eye surgeries

Check any of the following that you have had:

If Other Eye Disorders, please explain:

Are you pregnant or nursing?

No
Yes

Do you wear glasses?

No
Yes

If Yes, how old is your present pair of lenses?

Do you wear overnight orthokeratology molds?

No
Yes

AOK

If Yes, how old is your present pair of molds?

Do you wear contact lenses?

No
Yes

If Yes, how old is your present pair of lenses?

Type of Contact Lenses:

Are they comfortable?

No
Yes

Family History

Note any family history (parents, grandparents, siblings, children, living or deceased) for the following conditions. When listing relationship, if a grandparent, please specify maternal or paternal.

Disease/Condition

If Other, please explain:

If Yes to any of the above, please explain:

Please indicate which family member has the condition: Mother, Father, Child, Maternal Grandmother or Grandfather, Paternal Grandmother or Grandfather, Distant Relative

Social History

This information is kept strictly confidential. You may discuss this portion directly with the doctor if you prefer. Please check the box below of you prefer to discuss with the doctor instead.

I prefer to discuss my Social History information directly with my doctor.

Yes

Do you drive?

No
Yes

If Yes, do you have visual difficulty when driving?

No
Yes

If Yes, please describe:

Do you use tobacco products?

No
Yes

If Yes, list type/amount/how long:

Do you drink alcohol?

No
Yes

If Yes, list type/amount/how long:

Do you use illegal drugs?

No
Yes

If Yes, list type/amount/how long:

Have you ever been exposed to or infected with:

REVIEW OF SYSTEMS

Do you currently or have you ever had any problems in the following areas?

Constitutional

Fever, Weight Loss/Gain

No
Yes

Integumentary (Skin)

No
Yes

Neurological

Headaches

No
Yes

Migraines

No
Yes

Seizures

No
Yes

Eyes

Loss of Vision

No
Yes

Blurred Vision

No
Yes

Distorted Vision/Halos

No
Yes

Loss of Side Vision

No
Yes

Double Vision

No
Yes

Dryness

No
Yes

Mucous Discharge

No
Yes

Redness

No
Yes

Sandy or Gritty Feeling

No
Yes

Itching

No
Yes

Burning

No
Yes

Foreign Body Sensation

No
Yes

Excess Tearing/Watering

No
Yes

Glare/Light Sensitivity

No
Yes

Eye Pain or Soreness

No
Yes

Chronic Infection, Eye or Lid

No
Yes

Styes or Chalazion

No
Yes

Flashes/Floaters in Vision

No
Yes

Tired Eyes

No
Yes

Endocrine

Thyroid/Other Glands

No
Yes

Elevated Cholesterol

No
Yes

Cancer

No
Yes

Ears, Nose, Mouth, Throat

Sinus Congestion

No
Yes

Runny Nose

No
Yes

Post-Nasal Drip

No
Yes

Chronic Cough

No
Yes

Dry Thoat/Mouth

No
Yes

Allergies/Hay Fever

No
Yes

Respiratory

Asthma

No
Yes

Chronic Bronchitis

No
Yes

Emphysema

No
Yes

Vascular/Cardiovascular

Diabetes

No
Yes

Heart Pain

No
Yes

High Blood Pressure

No
Yes

Vascular Disease

No
Yes

Gastrointestinal

Diarrhea

No
Yes

Constipation

No
Yes

Genitourinary

Genitals/Kidney/Bladder

No
Yes

Bones/Joints/Muscles

Rheumatoid Arthritis

No
Yes

Muscle Pain

No
Yes

Joint Pain

No
Yes

Lymphatic/Hematologic

Anemia

No
Yes

Bleeding Problems

No
Yes

Allergic/Immunologic

No
Yes

Psychiatric

No
Yes

If you answered Yes to any of the above or have a condition not listed, please explain and list medications:

Privacy Policy

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Health Information Protection*

I have read and agree to the Privacy Policy

Signature*

Date*

Comments

This field is for validation purposes and should be left unchanged.

New Patient Registration & Medical History Form (NYC)