Advantage Eyecare New Patient

Advantage Eyecare New Patient Form

Today's Date
MM slash DD slash YYYY
Name
First Middle Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Date of Birth
MM slash DD slash YYYY
Sex
- Male
- Female
Home Phone
Work Phone Number
Cell Phone
Is it okay to TEXT reminders for appointments or to notify you that your order is in?
- Yes
- No
Email

** Emails will be used to confirm appointments, notify of orders, to notify of special promotions and to pass along eye health information.
Ethnicity
- Hispanic or Latino
- Not Hispanic or Latino
- Native Hawaiian/other Pacific Island
Race
- White
- Asian
- Black
Language Preference
- English
- Spanish
Family Members that are patients
Name Do they live with you? Date of birth Relationship
Insurance Information
Who is the cardholder of the insurance?
Date of birth
MM slash DD slash YYYY
Employer
Cardholder Social Security
Address of Cardholder
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

If not the same as the patient
Cardholder's Phone Number
Cardholder's Alternate Phone Number
Your Ocular History
- Cataracts
- Cataract Surgery: Left Eye
- Cataract Surgery: Right Eye
- Cataract Surgery: Both Eyes
- Glaucoma
- Lazy Eye
- Eye Injury
- Eye Disease
- Eye Surgery
- Other
Date of Cataract Surgery on Left Eye
MM slash DD slash YYYY
Date of Cataract Surgery on Right Eye
MM slash DD slash YYYY
Date of Cataract Surgery on Both Eyes
MM slash DD slash YYYY
Describe your eye injury
Describe your eye disease
Describe your eye surgery
Describe your "Other" ocular history
Family History
- Cataracts
- Lazy Eye
- Macular Degeneration
- Glaucoma
- Other Eye Diseases
- Diabetes
- Cancer
Describe your Family History of "Other Eye Diseases"
Please Specify the type of Cancer in your Family History
Please Describe any Other Conditions in your Family History
List your current medications
Name of medication Dosage Taken how often? Reason prescribed

If you take more than one medication, please use the plus symbol to the right of the field to enter more.
List your medication allergies

If you have more than one non-medication allergy, please use the plus symbol to the right of the field to enter more.
List other Non-Medication Allergies
Review of Systems
Cardiovascular
- Angina
- Arrhythmia
- Arterioscierosis
- Cardiovascular Disease
- Coagulation Disorder
- Congestive Heart Disease
- Elevated Cholesterol
- Endocarditis
- Heart Murmur
- Heart Palpitations
- High Blood Pressure
- Mitral Valve Prolapse
- Heart Attack
- Stroke
Constitutional
- Appetite (Excess)
- Appetite (Loss)
- Anemia
- Blackouts
- Car sickness
- Chills
- Colds
- Constipation
- Coughing
- Cramps
- Disorientation
- Dizziness
- Fainting
- Fatigue
- Fever
- Growth (Excess)
- Hunger (Excess)
- Nausea
- Night Sweats
- Nosebleeds
- Sleep (irregularly)
- Sweating
- Thirst (Excess)
- Vomitiing
- Weight gain
- Weight loss
persistent symptoms of:
Hematologic/Lympatic
- Anemia
- Breast Carcinoma
- Cavernous Sinus Thromb
- Coagulation Disorder
- Hematologic Disorder
- Hodgkins Disease
- Leukemia
- Lymphatic Cancer
- Pernicious Anemia
- Polycuthemia
- Sickle Cell Disease
- Temporal Arteritis
- Thalassemia
- Varicose Veins
Endocrine
- Cholesterol
- Crohn's Disease
- Diabetes
- Diabetic Suspect
- Hperlipoproteinemia
- Hypoglycemia
- Pituitary Disorder
- Renal Disease
- Hyperthyroidism
- Thyroid Disorder
Type of Diabetes
How many years have you had diabetes
Genitourinary
- Amnorrhea
- Bladder Infections
- Pregnancy: Ectopic
- Impotence
- Kidney Stones
- Menopause
- Ovarian Cyst
- Ovarian Tumor
- Plevic Inflammatory Disease
- Prostate Disorder
- Prostate Cancer
- Sexually Transmitted
- Syphilis
- Uterine Cancer
Gastrointestinal
- Acid-Reflux Syndrome
- Alcoholism
- Cancer: Colon
- Cancer: Liver
- Cancer Other
- Cirrhosis
- Colitis
- Diarrhea
- Diverticulosis
- Gall Bladded
- Gall Stones
- Gardner's Syndrome
- Gastritis
- Gastroenteritis
- Gastroenteritis Reflux
- Heptatitis
- Hepatic Disease
- Hiatus Hernia
- Inflammatory Bowel
- Intestinal Obstruction
- Jaundice
- Pancreatitus
- Ulcer Duodenal
- Ulcer Stomach
- Whipple's Disease
Head
- Chronic Cough
- Dental Disorder
- Dry Mouth
- Ear Infection
- Encephalitis
- Gingivitus
- Headaches
- Headaches (Cluster)
- Headaches (Migraine)
- Head Colds
- Hearing loss (full)
- Hearing loss (impaired)
- Meniere's Syndrome
- Sinusititus
Integumentary
- Acne
- Acne Rosacea
- Albinism
- Atopic Dermatitis
- Basal Cell Nevus Syndrome
- Cicatricial Pemphigoid
- Contact Dermatitis
- Dermatitis
- Dry Skin
- Erythema Mutiforme
- Erythema Nodosum
- Hermangioma
- Hypertrichosis
- Impetigo
Immunologic
- Acquired Immunodeficiency
- AIDS
- Bacterial Infection
- Chicken Pox
- Cytomegaloivirus Infection
- Diphtheria
- Endophthalmitis
- Herpes Simplex
- Herpes Zoster
- Histolasmosis
- HIV positive
- Influenza
- Lyme Disease
- Measles
- Mononucleosis
- Molluscum Contagiosum
- Mumps
- Newcastle Disease
- Reye's Syndrome
- Rheumatic Fever
- Rubella
- Sarciudisus
- Sjorgen's Syndrome
- Staphylococcus Infection
- Streptococcus Infection
- Syphiis
- Tetanus
- Tuberculosis
- Viral Infection
Respiratory
- Asthma
- Asthma, excercise induced
- Bronchitis
- Cancer, Lung
- COPD
- Cystic Fibrosis
- Emphysema
- Lund Disease
- Lung Cancer
- Pneumonia
- Pulmonary Insufficiency
- Respiratory Disfunction
- Sarcoidosis
- Smoker (Heavy)
- Tuberculosis
Musculoskeletal
- Ankylosing spondylititiis
- Arthriis
- Arthritis Rheymatoid
- Down's Syndrome
- Marfan's Syndrome
- Musualr Dystrophy
- Myasthenia Gravis
- Osteoporosis (Early)
- Osteoporosis (Advanced)
- Paget's Disease
- Polymyalgia Rheumatica
- Sacroilitis
- Scoliosis
- Skeletal Disorder
- Tuberculosis
Neurological
- Bell's Palsy
- Brain Damage
- Brain Tumor
- Cerebral Palsy
- Dyslexia
- Encephalitis
- Epilepsy
- Headache
- Headache (Cluster)
- Headache (Migraine)
- Horner's Syndrome
- Hysteria
- Malingering
- Muscular Dystrophy
- Multiple Sclerosis
- Myathenia Gravis
- Neuraigia
- Neurofibromatosis
- Nystagmus
- Olfactory Disorder
- Ophthalmolegia
- Parkinson's Disease
- Seizure Disorder
- Spinal Cord Injury
- Sturge-Weber Syndrome
- Trigeminal Neuralgia
- Tuberous Sclerosis
- Vertigo
- Von Hippel-Lindue Disease
Psychiatric
- Attention Disorder (ADD)
- Alcoholism
- Alzheimer's Disease
- Anorexia
- Anxiety Disorder
- Autism
- Bi-Polar Disorder
- Brain Damage (Trauma)
- Bulimia
- Delusions
- Dementia
- Depression
- Drug Dependency (Current)
- Drug Dependency (Past)
- Illusions
- Insomnia
- Learning Disablity
- Memory Loss (short-term)
- Mentally Challenged
- Mental Retardation
- Mood Disorder
- Orientation Disorder
- Personality Disorder
- Schizophrenia
- Psychiatric Disorder
- Suicidal Ideation
Are you a smoker?
- Yes
- No
If you are a smoker, how much, and how long have you smoked?
How much? How long?
Have you ever smoked?
- Yes
- No
How long ago did you quit smoking?
I authorize Dr. Rutan to release to my insurance carriers, including Medicare, Medicaid, and Medicare Supplements to provide any information required to resubmit any denied or incorrectly paid claims. This authorization remains in effect until withdrawn by me*
Signature
Date
MM slash DD slash YYYY
I acknowledge that I received a copy of Charles H. Rutan O.D.'s Notice of Privacy Practices
Signature
Date
MM slash DD slash YYYY
Name of person responsible for the account
First Last
Date of birth
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Social Security Number
Relationship to patient
Phone Number
Signature*
Date
MM slash DD slash YYYY

Name	Do they live with you?	Date of birth	Relationship

Name of medication	Dosage	Taken how often?	Reason prescribed

Advantage Eyecare New Patient Form

Insurance Information

Review of Systems