Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev.

Address:
City:		State/ Zip Code	MO

Home Phone:		Work Phone:
Cell Phone:		Alerts:
SSN		Email
Date of Birth:		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Unknown Single Married Separated Divorced Widowed Child	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Cunningham, Thomas J. Dr. Lane, Michael Dr. Miles, Judith Dr. Lyman, John C. Dr. VanCardo, Julie Dr. Hicks, Kevin Dr. Mahurin, Jennifer Dr. Butler, Ralph	Misc /Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev.

Address

City	State	Zip Code
	MO

Home Phone:
Work Phone:

Insurance 1

Insurance Information

Insurance Name:	None AARP Advantra GHP Aetna Aetna Discount Plan Aetna Medicare AlwaysVision AmeriBen/IEC Group American Administrative Group, Inc. American Family Ins. American Republic Ins. Co. Anthem BCBC HMO Anthem BCBS PPO Bankers Life and Casalty Co. Benefit Plan Administrators Care Management Resources Careington International Caremark Carpenters Health And Welfare CDS Group Health Central State SE&SW Health Central States SE And SW Areas ChampVA CIGNA CIGNA STL CIGNA STL Pepsi Combined Conn General Life Ins Conseco Ins. Co. Continental Life Coventry Health Care Deseret Mutual Diversified Administration Corp. (PHCS) Essence Healthcare EyeMed FARMERS INSURANCE GROUP FIRST HEALTH Fiserv Health Francis Howell GE Life GE Vision GEHA Ghp Gift Of Sight Globe Life And Accident Ins. GM INSURANCE/METROPOLITAN LIFE GM Vision Plan/ Met Life Golden Rule UHC GOS Great- West Healthcare HealthChoice HealthLink HMO HealthLink PPO Healthscope Benefits Humana IBEW, Local No.1, Health and Welfare Fund Infinity Trust Senior Medical Ins. Plan Innovative Benefits Group Interstate Hotels IUOE Local 513 Welfare Fund John Hancock Ins. Kanawha Ins. Co. KFC Lions Club Medi-Met Mercy Health Plans Meritain Health Met-Life Metimet Metimet-SWB Telephone Metimet AT&T MetraHealth Metropolitan Life Ins. Mid-County YMCA Mo. Medicare Services Monsanto Chemical Mutual Of Omaha National Imaging And Mapping National States Insurance New Insurance Opticare (Medicare Complete) Opticare Vision Plan Pennsylvania Life PHCS Physicians Mutual Pipefitter's Welfare Education Pipefitter Local #533 Premier Benefits, a Mercy Plans Co. Premier Plus Principal Life Insurance Co. Protective Vision Plan Quality Benefits, LLC Railroad Medicare (Palmetto GBA) Relizon Relizon United MedicalResource Reynolds And Reynolds SAFECO Life Insurance SCI+ Scott & White Health Plan SecureHorizons Self Insured Services Co. Standard Life Star HRG State Farm Health Ins. Station Casino Plus- CDS Superior Vision Services,Inc. Suppliment TDEFIC The Loomis Company Tri-Care TROA Group Health Insurance UCT-United Comm. Travelers Of UFCW Welfare Fund Benefits UniCare United Health Care United Medical Resources, Inc. Unknown USAA Life Insurance Co. VCA VSP
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

 *Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
*Primary Date of Birth:
Employer/School:

Insurance 2

Insurance Information

Insurance Name:	None AARP Advantra GHP Aetna Aetna Discount Plan Aetna Medicare AlwaysVision AmeriBen/IEC Group American Administrative Group, Inc. American Family Ins. American Republic Ins. Co. Anthem BCBC HMO Anthem BCBS PPO Bankers Life and Casalty Co. Benefit Plan Administrators Care Management Resources Careington International Caremark Carpenters Health And Welfare CDS Group Health Central State SE&SW Health Central States SE And SW Areas ChampVA CIGNA CIGNA STL CIGNA STL Pepsi Combined Conn General Life Ins Conseco Ins. Co. Continental Life Coventry Health Care Deseret Mutual Diversified Administration Corp. (PHCS) Essence Healthcare EyeMed FARMERS INSURANCE GROUP FIRST HEALTH Fiserv Health Francis Howell GE Life GE Vision GEHA Ghp Gift Of Sight Globe Life And Accident Ins. GM INSURANCE/METROPOLITAN LIFE GM Vision Plan/ Met Life Golden Rule UHC GOS Great- West Healthcare HealthChoice HealthLink HMO HealthLink PPO Healthscope Benefits Humana IBEW, Local No.1, Health and Welfare Fund Infinity Trust Senior Medical Ins. Plan Innovative Benefits Group Interstate Hotels IUOE Local 513 Welfare Fund John Hancock Ins. Kanawha Ins. Co. KFC Lions Club Medi-Met Mercy Health Plans Meritain Health Met-Life Metimet Metimet-SWB Telephone Metimet AT&T MetraHealth Metropolitan Life Ins. Mid-County YMCA Mo. Medicare Services Monsanto Chemical Mutual Of Omaha National Imaging And Mapping National States Insurance New Insurance Opticare (Medicare Complete) Opticare Vision Plan Pennsylvania Life PHCS Physicians Mutual Pipefitter's Welfare Education Pipefitter Local #533 Premier Benefits, a Mercy Plans Co. Premier Plus Principal Life Insurance Co. Protective Vision Plan Quality Benefits, LLC Railroad Medicare (Palmetto GBA) Relizon Relizon United MedicalResource Reynolds And Reynolds SAFECO Life Insurance SCI+ Scott & White Health Plan SecureHorizons Self Insured Services Co. Standard Life Star HRG State Farm Health Ins. Station Casino Plus- CDS Superior Vision Services,Inc. Suppliment TDEFIC The Loomis Company Tri-Care TROA Group Health Insurance UCT-United Comm. Travelers Of UFCW Welfare Fund Benefits UniCare United Health Care United Medical Resources, Inc. Unknown USAA Life Insurance Co. VCA VSP
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

 *Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
*Primary Date of Birth:
Employer/School:

Insurance 3

Insurance Information

Insurance Name:	None AARP Advantra GHP Aetna Aetna Discount Plan Aetna Medicare AlwaysVision AmeriBen/IEC Group American Administrative Group, Inc. American Family Ins. American Republic Ins. Co. Anthem BCBC HMO Anthem BCBS PPO Bankers Life and Casalty Co. Benefit Plan Administrators Care Management Resources Careington International Caremark Carpenters Health And Welfare CDS Group Health Central State SE&SW Health Central States SE And SW Areas ChampVA CIGNA CIGNA STL CIGNA STL Pepsi Combined Conn General Life Ins Conseco Ins. Co. Continental Life Coventry Health Care Deseret Mutual Diversified Administration Corp. (PHCS) Essence Healthcare EyeMed FARMERS INSURANCE GROUP FIRST HEALTH Fiserv Health Francis Howell GE Life GE Vision GEHA Ghp Gift Of Sight Globe Life And Accident Ins. GM INSURANCE/METROPOLITAN LIFE GM Vision Plan/ Met Life Golden Rule UHC GOS Great- West Healthcare HealthChoice HealthLink HMO HealthLink PPO Healthscope Benefits Humana IBEW, Local No.1, Health and Welfare Fund Infinity Trust Senior Medical Ins. Plan Innovative Benefits Group Interstate Hotels IUOE Local 513 Welfare Fund John Hancock Ins. Kanawha Ins. Co. KFC Lions Club Medi-Met Mercy Health Plans Meritain Health Met-Life Metimet Metimet-SWB Telephone Metimet AT&T MetraHealth Metropolitan Life Ins. Mid-County YMCA Mo. Medicare Services Monsanto Chemical Mutual Of Omaha National Imaging And Mapping National States Insurance New Insurance Opticare (Medicare Complete) Opticare Vision Plan Pennsylvania Life PHCS Physicians Mutual Pipefitter's Welfare Education Pipefitter Local #533 Premier Benefits, a Mercy Plans Co. Premier Plus Principal Life Insurance Co. Protective Vision Plan Quality Benefits, LLC Railroad Medicare (Palmetto GBA) Relizon Relizon United MedicalResource Reynolds And Reynolds SAFECO Life Insurance SCI+ Scott & White Health Plan SecureHorizons Self Insured Services Co. Standard Life Star HRG State Farm Health Ins. Station Casino Plus- CDS Superior Vision Services,Inc. Suppliment TDEFIC The Loomis Company Tri-Care TROA Group Health Insurance UCT-United Comm. Travelers Of UFCW Welfare Fund Benefits UniCare United Health Care United Medical Resources, Inc. Unknown USAA Life Insurance Co. VCA VSP
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

 *Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
*Primary Date of Birth:
Employer/School:

Medical History

 

Family Ocular History:

Family Medical History:

Current Medications:

Allergies:

 

Do you do any of the following:

Drink Alcohol?		Smoke?
no yes		no yes

Have Occupational Exposure?		Illegal Drugs?
no yes		no yes

 

Do you have any of the following:

Floaters	STD's, HIV, Hepatitis	High Blood Pressure
no yes	no yes	no yes

Light Sensitivity	Heart Disease	Flashes of Light
no yes	no yes	no yes

Watery Eyes	Gastrointestinal problems	Eye Pain
no yes	no yes	no yes

Burning eyes	Cancer	Itchy eyes
no yes	no yes	no yes

Red eyes	Heart Disease	Chronic eye infections
no yes	no yes	no yes

Stye	Asthma	Blurred Vision
no yes	no yes	no yes

Loss of Vision	Skin Disorder (Rashes, Eczema)	Double Vision
no yes	no yes	no yes

Cataracts	Genitals/Urinary (Prostate, Dialysis)	Glaucoma
no yes	no yes	no yes

Blindness	Anemia, Leukemia, Hodgkin's	Lungs (COPD, Emphysema)
no yes	no yes	no yes

Ear, Nose, & Throat	Arthritis / Joint pain	Macular Degeneration
no yes	no yes	no yes

Diabetes	Kidney disease	Neurological ( Headache, Seizure, Stroke)
no yes	no yes	no yes

Unexpected weight loss/gain	Thyroid Problems?	Pregnant or nursing?
no yes	no yes	no yes

Interested in Contacts?

no yes

Ever worn Contacts?

Yes No

Primary Physician

Last Eye Exam

By Dr.

Thomas Cunningham Michael Lane John Lyman Julie Van Cardo Judith Miles Jennifer Mahurin

 

Vision Therapy

Was your child born premature?
									no yes

Takes hours to do 20 minutes of  homework?
									none

Delays or difficulties with learning to speak?
									no yes

Reverses words or letters ( b for d, saw for was)?
									no yes

Rubs eyes after reading for a short time period?
									yes no

Holding things too close?
									no yes

Head turning when reading?
									no yes

Squinting one or both eyes?
									no yes

Loses place when reading?
									no yes

Covering one eye?
									no yes

Frequent letter reversals?
									no yes

Poor eye-hand coordination?
									no yes

Poor reading comprehension?
									no yes

Head Trauma?

no yes