New Patient Forms


To save time on the day of your appointment, please fill out the following form and click the submit button
at the bottom. Your information will be transmitted via a secure connection.
You may also download, print, and fill out a paper copy here.

First Name:
Last Name:
Date of Birth:
Gender: Male     Female
Address:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Cell Phone:
Email:



PAST EYE PROBLEMS
Please check all that apply:
Allergies to Eye Drops History of Cataract Cataract Surgery Glaucoma Eye injury
Floaters Macular degeneration Retinal tear Retinal detachment
Pterygium Strabismus Lazy Eye Blepharitis Dry Eyes
Scratch on eye Corneal ulcer Cornea transplant Previous LASIK

Please list any other past eye problems below:




PAST MEDICAL PROBLEMS
Please check all that apply:
Diabetes High blood pressure High cholesterol Heart attack Seizure disorder
Asthma COPD Chronic bronchitis Seasonal allergies Sinus infections
Arthritis Rheumatoid arthritis Lupus Sjogrens Syndrome Gout
Heartburn Irritable bowel Anemia Bleeding disorder Gallbladder disease
Depression Anxiety Overactive thyroid Low thyroid Migraines

Please list any other past medical problems below:



Please list all surgical procedures you have had below:




CURRENT MEDICATIONS

Please list all EYEDROPS that you currently use:


Please list all OTHER MEDICATIONS that you currently take:


Please list any ALLERGIES to medications that you have:





REVIEW OF SYMPTOMS:
Please check all symptoms that you have had within the last month.

General Health: Weight loss Weight gain Fatigue Loss of appetite
     
Eyes: Blurred vision Loss of side vision Itching/Burning Double vision
  Dry eyes Eye pain Crusting/Discharge Eye strain
  Haloes Glare Headache Trouble reading
     
Ears: Ear pain Hearing loss Ringing in ears Dizziness
     
Nose/Throat: Runny nose Nasal congestion Sore throat Trouble swallowing
     
Heart/Lungs: Chest pain Shortness of breath Coughing Wheezing
     
GI: Heartburn Nausea/Vomiting Abdominal pain Diarrhea
     
Urinary: Blood in urine Increased urination Difficulty urinating Pain with urination
     
Musculoskelatal:     Back pain Pain in muscles/joints Limited range of motion
     
Skin: Rash Sores Changing moles
     
Neurological: Seizures Weakness/Numbness Memory problems Loss of coordination
     
Blood: Easy bruising Nosebleeds Swollen hands/feet Blood transfusion
     
Immune: Seasonal allergies Swollen glands Previous STDs HIV infection
     
Mental Health: Depression Anxiety Mood swings



SOCIAL HISTORY
Please check all that apply:
   Use tobacco products
   Drink alcohol
   Wear RGP contacts
   Wear soft contacts



FAMILY HISTORY
Please check all that apply to someone in your family:
   Blindness
   Glaucoma
   Cataract surgery prior to age 50
   Macular degeneration
   Retinal detachment
   Keratoconus
   Corneal dystrophy

   Diabetes
   Heart disease
   High blood pressure
   Lupus
   Cancer
   Sickle cell anemia
   Arthritis