New Patient Form

Demographics

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

Address: City: State/ZipCode TN TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD UT VT VI VA WA WV WI WY

Home Phone: Work Phone: Other Phone: Cell Phone: Preferred Contact Method: Home Phone Work Phone Cell Phone Other Phone Text Message Email SSN Email Birthday Occupation Sex Male Female Employment Status Employed Full-Time Student Part-Time Student Marital Status Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed Employer/School Name Misc/Guardian

Billing Information

Is The Billing Address the Same?

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

Address

City	State	ZipCode
	TN TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None A.A.R.P. AARP Accordia National Admiral Life Insurance Co Adventist Risk Management Aerospace Contractors' Trust Aetna Aetna AETNA AETNA-Frito Lay AETNA-JCPenney AETNA-Mail Well Corporation AETNA-Pepsi-Cola AETNA-ROCK-TENN AETNA-Southern TN Medical AETNA Health Plans Of TN, Inc. Aetna Life Insurance Company Aetna US Healthcare AETNA USHC AMA American Contiental Insurance American Family Ins. American Medical Security American National Life Ins American Pioneer American Republic Insurance Co AmeriChoice Amerigroup Ameritus Anthem Blue Cross Blue Sheild APWU Araiza Company Arkansas Blue Cross/Blue Shie ASEA/AFSCME Local 52 Health Benefits Trust Assoication & Society Ins Corp Assurant Health Avesis AVMA Group Health Bankers Fidelity Bankers Life And Casualty BC/BS BlueAdvantage Operations BCBS - Memphis BCBSTN Bench Mark Tool Benesight Blue Cross Blue Sheild Of GA Blue Cross Blue Sheild Of Mich Blue Cross Blue Shield of Texas Blue Cross/ Blue Shield Of Al BLUECARE Brentwood Services Bridgestone Safety BRMS Brown & Brown Benefits CARE Caremark Center Care Central Reserve Life Ins. Co. Central States CHAMPVA Cigna Cigna Cigna Cigna Cigna CIGNA CIGNA Cigna Government Services DME Cigna Health Care Cigna Healthcare City Of Manchester CNA Co-ordinated Benefit Plans, LLC Coast to Coast Vision Colonial Penn Health Insurance Columbia Healthcare Network Combined Insurance Co. Of Amer Commerce Benefits Group Community Care Network Community Health Alliance Comp Benefits(Humana/VCP) Compainion Property & Casualty Complete Health Concordia Health Plan Connecticut General Connecticut General-Avon Connecticut General-Kaman Corp Connecticut General-Stanley Continental General Continental Life Cooperative Benefit Adm CoreSource, Inc. Covenant Adminstrators,Inc Eba&m Equicor ESIS Essilor Safety Family Life Insurance Company Federated Insurance Finlay Industries, Inc. First American First Community Health Plan, Inc First Health Fiserv Health FMH CoreSource Foreign Service Benefit Plan Fortis Benefits Insurance Co. Fortis Insurance Co Freedom Life Insurance Co. of America GEHA General American General American General American General American Life Ins. Co Gerber Life Insurance Golden Rule Insurance Company Goodyear Tire And Rubber Co Great West Life 7 Annuity Group and Pension Administrators Guarantee Trust Life Insurance Co. Guardian GWH-Cigna GWH-Cigna Harrington Harrington/Brookfield Hartford Accident & Indemnity Hartford Life Health Claim Hartford Life Health Claim Off Hartford Life Senior Medical Health 1-2-3 Health 1-2-3 Platinum HEALTH CHOICE, INC. Health Cost Solutions Health Net HEALTH NET Health Net-Stan Mcnabb Health Net - Earl Swensson Health Net - Tenn Care HEALTH NET, INC. Health Partners Health Partners,Inc Health Risk Management, Inc. Healthnet-Pittman & Associates HEALTHNET PROVIDERS HEALTHNET, INC. HealthSCOPE Benefits HealthScoper Benefits, Inc Healthsource-Provident Healthsource - Provident HealthSpring HealthyAdvantage HealthSpring, Inc HHPO Highmark Services Hill Pack Insurance Agency HMO BLUE Hometown Health Network Humana Claims Humana Claims Dept Humana Health Care Hunt & Taylor Ibew-Neca Southwestern Health Ideal Life Insurance Insurance Claims Service Inc Intracorp/Accumed Services Ira A Watson Co. John Alden Life Insurance Co. John Deere Health Plan,Inc John Hancock Mutual John Hancock Mutual-Sheller John Hancock Mutual-Whirlpool John Hancock Mutual - CSA JOHN HANCOCK MUTUAL LIF John Hancock Mutual Life Ins. John Hancock Mutual Life Ins. Kemper National Services Kimberly-Clark Preferred Servr KIRKE-VAN ORSDEL INC. KLAIS & COMPANY, INC. Klais & Company,Inc Liberty Life Auto Club Liberty Mutual Life Care Centers Of America Life Insurance Co. Of Georgia Life Investors Ins. Life Investors Ins. Of America LifeRe Insurance Company Lincoln National Life Line Construction Benefit Fund Logistics Health Inc. Loyal American Life Insurance, Co Macgregor Golf Company Mail Handlers Benefit Plan Managing Underwriters, Inc. March Vision Marco Group Health Plan Marquette National Marquette National Life Insurance Company Marsh Advantage America Marsh Affinity Group MASS MUTUAL MASS. MUTUAL MASSACHUSETTS MUTUAL MASSMUTUAL MASSMUTUAL GROUP CLAIM McDowell Agency,Inc Medica Medicaid Medical Mutual Of Ohio Medicare Medicare - Railroad Medico Life Insurance Co. MEDIGAP # 007379896 MEDIPLUS MEDIPLUS/The Hartford Meritain Health Met Life Met Life-Saturn Health Claims Met Life - Met Life - Sears Met Life -GM MetLife-Guinness American, Inc Metra Health Metrahealth MetraHealth METROPOLITAN (PEPSI CO) Metropolitan Life-American Can Metropolitan Life -Amer. Can METROPOLITAN LIFE INS. Metropolitan Life Ins.-Wilson Metropolitan Life Ins. Co. Metropolitan Life Insurance METROPOLITAN LIFE INSURANCE Middle Tennessee State University Midwest Operating Engineers Midwestern Insurance Alliance Monumental Life Insurance Co. Motion Industries MSC MTMC Employee Health Plan Mutual Of Omaha Mutual Protective/Medico Life NALC Health Benefit Plan NAME National Assoc. Of Carriers National Financial Ins. Co. National Foundation Life Ins. National Group Ins, Co. NATIONAL HOME LIFE CO. NATIONAL LIFE & ACC. NATIONAL STATES INS. National States Insurance National Travelers Life Co Nationwide Insurance Nationwide Insurance Enterpris NATIONWIDE MUTUAL INS. NEA Group Insurance New Era Life Ins New Era Life Insurance Co New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New York Life Ins. Co. Newera Life Insurance Co. NewMarket Dimensions NHC Health Benefit Plan North America Administrators Norwest Financial Novanet/Signature NTCA/SMC-ASHVILLE SER. CENTE OMAHA HEALTH CARE SER. CENTER Opticare Optum Health P M Group Pacific Mutual Life Insurance PALMETTO GOV BENEFITS ADMIN Pan American Life Ins. Co. PAN AMERICAN LIFE INS.C PCS Health Systems Pension Assoc. PHCS Nashville PHCS UMR Philadelphia American Life Phoenix Healthcare Of TN, Inc. PHP TnCare Physicians Mutual Insurance Co PILOT LIFE INSUR. CO. PIONEER LIFE PIONEER LIFE INSURANCE Pioneer Life Insurance Co. PIONEER LIFE INSURANCE CO. Pittman & Assoc, Inc. Pittman & Associates Plumbers & Pipefitters Fund 572 Plummers & Steamfitters Local 43 POMCO Group Postmasters Benefit Plan Preferred Health Partnership Preferred Health Plan, Inc. Principal Life Insurance Co Principal Life Ins. Co. Principal Life Insurance Co Principal Mutual Life Ins. Co. Principle Life Insurance Co. Provident PROVIDENT Provident-Harton Hospital Provident - Nissan Motor Corp. Provident Life &accident Ins Provident Life And Accident Prudential-Rich'S Prudential Ins. Co. PRUDENTIAL INSURANCE CO Pyramid Life Pyramid Life Insurance Co RBMS, LLc Regional West Medical Center Reserve Health Readiness Progr Reserve National Ins. Co. Retirement Plans Office Of SDA Robey-Barber Insurance Serv. Royal Insurance Rural Carrier Benefit Plan SAI A CORESOURCE COMPANY Seabury & Smith, Inc Seafarer's Welfare Plan Security Life Ins Co Shaw Industries Shaw Medical Shaw Medical Claims Accordia Sheet Metal Workers National Sheffield Of Tennessee SHELBYVILLE POWER CO. Shelbyville Power System Shelter Life Insurance Co. Signature Health Signature Health Alliance SmartHealth Southern Electrical Health Fun Southland Benefit Solutions Southland National Insurance Southwest Administrators Spectera-Bell South Unit SRC STANDARD LIFE INS. STANDARD LIFE INSURANCE CO Standard Life Insurance Co. Star HRG Starmark State Farm Health Ins. State Farm Health Insurance State Farm Mutual STATE FARM MUTUAL State Health Benefit Plan STATE MUTUAL CO. STATE OF TENN MEDICAID State Of Tn (Children's Plan) Sterling Option 1 Sterling Option II Sun Healthcare Group, Inc, Superior National Superior Vision Services Teamcare Temtex Products,Inc. TennCare Select Tennessee Healthcare Tennessee Valley Operating Eng THC/MMS The City Of Manchester THE EATON BENEFITS Office The Eaton Benefits Payment Off THE EQUITABLE The Equitable Life Ins. The Farmers Bank The Funds The Guardian The Plan Handlers, Inc The Principal Financial Group The Prudential THE PRUDENTIAL The Prudential Ins. Co. Of Am. The Pyramid Life Ins. Co. The TPA, Inc. The Travelers THE TRAVELERS INS. The Travelers Insurance Co. The Ullico Family Of Companies The Union Labor Life Ins The Union Labor Life Ins. Co. THRG/HNN Tricare Tricare For Life UMR UMWA Health & Retirement Funds Union Bankers United American Insurance Company United Health Care United Healthcare United HealthCare United HealthCare United Healthcare Ins. Co United Healthcare Network, Inc UnitedHealthCare UnitedHealthcare Community Plan UnitedHealthcare Medicare Solutions USAA Life Insurance Co. VCP-Humana Vision Care Direct VSP VSP-Access Plan William C. Beeler And Co. Windsor Medicare Extra Woodmen of the World Young Life Beneftis Plan
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:
Birthday:
SSN:
Employer/School:

Secondary

Insurance Information

Insurance Name:	None A.A.R.P. AARP Accordia National Admiral Life Insurance Co Adventist Risk Management Aerospace Contractors' Trust Aetna Aetna AETNA AETNA-Frito Lay AETNA-JCPenney AETNA-Mail Well Corporation AETNA-Pepsi-Cola AETNA-ROCK-TENN AETNA-Southern TN Medical AETNA Health Plans Of TN, Inc. Aetna Life Insurance Company Aetna US Healthcare AETNA USHC AMA American Contiental Insurance American Family Ins. American Medical Security American National Life Ins American Pioneer American Republic Insurance Co AmeriChoice Amerigroup Ameritus Anthem Blue Cross Blue Sheild APWU Araiza Company Arkansas Blue Cross/Blue Shie ASEA/AFSCME Local 52 Health Benefits Trust Assoication & Society Ins Corp Assurant Health Avesis AVMA Group Health Bankers Fidelity Bankers Life And Casualty BC/BS BlueAdvantage Operations BCBS - Memphis BCBSTN Bench Mark Tool Benesight Blue Cross Blue Sheild Of GA Blue Cross Blue Sheild Of Mich Blue Cross Blue Shield of Texas Blue Cross/ Blue Shield Of Al BLUECARE Brentwood Services Bridgestone Safety BRMS Brown & Brown Benefits CARE Caremark Center Care Central Reserve Life Ins. Co. Central States CHAMPVA Cigna Cigna Cigna Cigna Cigna CIGNA CIGNA Cigna Government Services DME Cigna Health Care Cigna Healthcare City Of Manchester CNA Co-ordinated Benefit Plans, LLC Coast to Coast Vision Colonial Penn Health Insurance Columbia Healthcare Network Combined Insurance Co. Of Amer Commerce Benefits Group Community Care Network Community Health Alliance Comp Benefits(Humana/VCP) Compainion Property & Casualty Complete Health Concordia Health Plan Connecticut General Connecticut General-Avon Connecticut General-Kaman Corp Connecticut General-Stanley Continental General Continental Life Cooperative Benefit Adm CoreSource, Inc. Covenant Adminstrators,Inc Eba&m Equicor ESIS Essilor Safety Family Life Insurance Company Federated Insurance Finlay Industries, Inc. First American First Community Health Plan, Inc First Health Fiserv Health FMH CoreSource Foreign Service Benefit Plan Fortis Benefits Insurance Co. Fortis Insurance Co Freedom Life Insurance Co. of America GEHA General American General American General American General American Life Ins. Co Gerber Life Insurance Golden Rule Insurance Company Goodyear Tire And Rubber Co Great West Life 7 Annuity Group and Pension Administrators Guarantee Trust Life Insurance Co. Guardian GWH-Cigna GWH-Cigna Harrington Harrington/Brookfield Hartford Accident & Indemnity Hartford Life Health Claim Hartford Life Health Claim Off Hartford Life Senior Medical Health 1-2-3 Health 1-2-3 Platinum HEALTH CHOICE, INC. Health Cost Solutions Health Net HEALTH NET Health Net-Stan Mcnabb Health Net - Earl Swensson Health Net - Tenn Care HEALTH NET, INC. Health Partners Health Partners,Inc Health Risk Management, Inc. Healthnet-Pittman & Associates HEALTHNET PROVIDERS HEALTHNET, INC. HealthSCOPE Benefits HealthScoper Benefits, Inc Healthsource-Provident Healthsource - Provident HealthSpring HealthyAdvantage HealthSpring, Inc HHPO Highmark Services Hill Pack Insurance Agency HMO BLUE Hometown Health Network Humana Claims Humana Claims Dept Humana Health Care Hunt & Taylor Ibew-Neca Southwestern Health Ideal Life Insurance Insurance Claims Service Inc Intracorp/Accumed Services Ira A Watson Co. John Alden Life Insurance Co. John Deere Health Plan,Inc John Hancock Mutual John Hancock Mutual-Sheller John Hancock Mutual-Whirlpool John Hancock Mutual - CSA JOHN HANCOCK MUTUAL LIF John Hancock Mutual Life Ins. John Hancock Mutual Life Ins. Kemper National Services Kimberly-Clark Preferred Servr KIRKE-VAN ORSDEL INC. KLAIS & COMPANY, INC. Klais & Company,Inc Liberty Life Auto Club Liberty Mutual Life Care Centers Of America Life Insurance Co. Of Georgia Life Investors Ins. Life Investors Ins. Of America LifeRe Insurance Company Lincoln National Life Line Construction Benefit Fund Logistics Health Inc. Loyal American Life Insurance, Co Macgregor Golf Company Mail Handlers Benefit Plan Managing Underwriters, Inc. March Vision Marco Group Health Plan Marquette National Marquette National Life Insurance Company Marsh Advantage America Marsh Affinity Group MASS MUTUAL MASS. MUTUAL MASSACHUSETTS MUTUAL MASSMUTUAL MASSMUTUAL GROUP CLAIM McDowell Agency,Inc Medica Medicaid Medical Mutual Of Ohio Medicare Medicare - Railroad Medico Life Insurance Co. MEDIGAP # 007379896 MEDIPLUS MEDIPLUS/The Hartford Meritain Health Met Life Met Life-Saturn Health Claims Met Life - Met Life - Sears Met Life -GM MetLife-Guinness American, Inc Metra Health Metrahealth MetraHealth METROPOLITAN (PEPSI CO) Metropolitan Life-American Can Metropolitan Life -Amer. Can METROPOLITAN LIFE INS. Metropolitan Life Ins.-Wilson Metropolitan Life Ins. Co. Metropolitan Life Insurance METROPOLITAN LIFE INSURANCE Middle Tennessee State University Midwest Operating Engineers Midwestern Insurance Alliance Monumental Life Insurance Co. Motion Industries MSC MTMC Employee Health Plan Mutual Of Omaha Mutual Protective/Medico Life NALC Health Benefit Plan NAME National Assoc. Of Carriers National Financial Ins. Co. National Foundation Life Ins. National Group Ins, Co. NATIONAL HOME LIFE CO. NATIONAL LIFE & ACC. NATIONAL STATES INS. National States Insurance National Travelers Life Co Nationwide Insurance Nationwide Insurance Enterpris NATIONWIDE MUTUAL INS. NEA Group Insurance New Era Life Ins New Era Life Insurance Co New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New York Life Ins. Co. Newera Life Insurance Co. NewMarket Dimensions NHC Health Benefit Plan North America Administrators Norwest Financial Novanet/Signature NTCA/SMC-ASHVILLE SER. CENTE OMAHA HEALTH CARE SER. CENTER Opticare Optum Health P M Group Pacific Mutual Life Insurance PALMETTO GOV BENEFITS ADMIN Pan American Life Ins. Co. PAN AMERICAN LIFE INS.C PCS Health Systems Pension Assoc. PHCS Nashville PHCS UMR Philadelphia American Life Phoenix Healthcare Of TN, Inc. PHP TnCare Physicians Mutual Insurance Co PILOT LIFE INSUR. CO. PIONEER LIFE PIONEER LIFE INSURANCE Pioneer Life Insurance Co. PIONEER LIFE INSURANCE CO. Pittman & Assoc, Inc. Pittman & Associates Plumbers & Pipefitters Fund 572 Plummers & Steamfitters Local 43 POMCO Group Postmasters Benefit Plan Preferred Health Partnership Preferred Health Plan, Inc. Principal Life Insurance Co Principal Life Ins. Co. Principal Life Insurance Co Principal Mutual Life Ins. Co. Principle Life Insurance Co. Provident PROVIDENT Provident-Harton Hospital Provident - Nissan Motor Corp. Provident Life &accident Ins Provident Life And Accident Prudential-Rich'S Prudential Ins. Co. PRUDENTIAL INSURANCE CO Pyramid Life Pyramid Life Insurance Co RBMS, LLc Regional West Medical Center Reserve Health Readiness Progr Reserve National Ins. Co. Retirement Plans Office Of SDA Robey-Barber Insurance Serv. Royal Insurance Rural Carrier Benefit Plan SAI A CORESOURCE COMPANY Seabury & Smith, Inc Seafarer's Welfare Plan Security Life Ins Co Shaw Industries Shaw Medical Shaw Medical Claims Accordia Sheet Metal Workers National Sheffield Of Tennessee SHELBYVILLE POWER CO. Shelbyville Power System Shelter Life Insurance Co. Signature Health Signature Health Alliance SmartHealth Southern Electrical Health Fun Southland Benefit Solutions Southland National Insurance Southwest Administrators Spectera-Bell South Unit SRC STANDARD LIFE INS. STANDARD LIFE INSURANCE CO Standard Life Insurance Co. Star HRG Starmark State Farm Health Ins. State Farm Health Insurance State Farm Mutual STATE FARM MUTUAL State Health Benefit Plan STATE MUTUAL CO. STATE OF TENN MEDICAID State Of Tn (Children's Plan) Sterling Option 1 Sterling Option II Sun Healthcare Group, Inc, Superior National Superior Vision Services Teamcare Temtex Products,Inc. TennCare Select Tennessee Healthcare Tennessee Valley Operating Eng THC/MMS The City Of Manchester THE EATON BENEFITS Office The Eaton Benefits Payment Off THE EQUITABLE The Equitable Life Ins. The Farmers Bank The Funds The Guardian The Plan Handlers, Inc The Principal Financial Group The Prudential THE PRUDENTIAL The Prudential Ins. Co. Of Am. The Pyramid Life Ins. Co. The TPA, Inc. The Travelers THE TRAVELERS INS. The Travelers Insurance Co. The Ullico Family Of Companies The Union Labor Life Ins The Union Labor Life Ins. Co. THRG/HNN Tricare Tricare For Life UMR UMWA Health & Retirement Funds Union Bankers United American Insurance Company United Health Care United Healthcare United HealthCare United HealthCare United Healthcare Ins. Co United Healthcare Network, Inc UnitedHealthCare UnitedHealthcare Community Plan UnitedHealthcare Medicare Solutions USAA Life Insurance Co. VCP-Humana Vision Care Direct VSP VSP-Access Plan William C. Beeler And Co. Windsor Medicare Extra Woodmen of the World Young Life Beneftis Plan
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:
Birthday:
SSN:
Employer/School:

Tertiary

Insurance Information

Insurance Name:	None A.A.R.P. AARP Accordia National Admiral Life Insurance Co Adventist Risk Management Aerospace Contractors' Trust Aetna Aetna AETNA AETNA-Frito Lay AETNA-JCPenney AETNA-Mail Well Corporation AETNA-Pepsi-Cola AETNA-ROCK-TENN AETNA-Southern TN Medical AETNA Health Plans Of TN, Inc. Aetna Life Insurance Company Aetna US Healthcare AETNA USHC AMA American Contiental Insurance American Family Ins. American Medical Security American National Life Ins American Pioneer American Republic Insurance Co AmeriChoice Amerigroup Ameritus Anthem Blue Cross Blue Sheild APWU Araiza Company Arkansas Blue Cross/Blue Shie ASEA/AFSCME Local 52 Health Benefits Trust Assoication & Society Ins Corp Assurant Health Avesis AVMA Group Health Bankers Fidelity Bankers Life And Casualty BC/BS BlueAdvantage Operations BCBS - Memphis BCBSTN Bench Mark Tool Benesight Blue Cross Blue Sheild Of GA Blue Cross Blue Sheild Of Mich Blue Cross Blue Shield of Texas Blue Cross/ Blue Shield Of Al BLUECARE Brentwood Services Bridgestone Safety BRMS Brown & Brown Benefits CARE Caremark Center Care Central Reserve Life Ins. Co. Central States CHAMPVA Cigna Cigna Cigna Cigna Cigna CIGNA CIGNA Cigna Government Services DME Cigna Health Care Cigna Healthcare City Of Manchester CNA Co-ordinated Benefit Plans, LLC Coast to Coast Vision Colonial Penn Health Insurance Columbia Healthcare Network Combined Insurance Co. Of Amer Commerce Benefits Group Community Care Network Community Health Alliance Comp Benefits(Humana/VCP) Compainion Property & Casualty Complete Health Concordia Health Plan Connecticut General Connecticut General-Avon Connecticut General-Kaman Corp Connecticut General-Stanley Continental General Continental Life Cooperative Benefit Adm CoreSource, Inc. Covenant Adminstrators,Inc Eba&m Equicor ESIS Essilor Safety Family Life Insurance Company Federated Insurance Finlay Industries, Inc. First American First Community Health Plan, Inc First Health Fiserv Health FMH CoreSource Foreign Service Benefit Plan Fortis Benefits Insurance Co. Fortis Insurance Co Freedom Life Insurance Co. of America GEHA General American General American General American General American Life Ins. Co Gerber Life Insurance Golden Rule Insurance Company Goodyear Tire And Rubber Co Great West Life 7 Annuity Group and Pension Administrators Guarantee Trust Life Insurance Co. Guardian GWH-Cigna GWH-Cigna Harrington Harrington/Brookfield Hartford Accident & Indemnity Hartford Life Health Claim Hartford Life Health Claim Off Hartford Life Senior Medical Health 1-2-3 Health 1-2-3 Platinum HEALTH CHOICE, INC. Health Cost Solutions Health Net HEALTH NET Health Net-Stan Mcnabb Health Net - Earl Swensson Health Net - Tenn Care HEALTH NET, INC. Health Partners Health Partners,Inc Health Risk Management, Inc. Healthnet-Pittman & Associates HEALTHNET PROVIDERS HEALTHNET, INC. HealthSCOPE Benefits HealthScoper Benefits, Inc Healthsource-Provident Healthsource - Provident HealthSpring HealthyAdvantage HealthSpring, Inc HHPO Highmark Services Hill Pack Insurance Agency HMO BLUE Hometown Health Network Humana Claims Humana Claims Dept Humana Health Care Hunt & Taylor Ibew-Neca Southwestern Health Ideal Life Insurance Insurance Claims Service Inc Intracorp/Accumed Services Ira A Watson Co. John Alden Life Insurance Co. John Deere Health Plan,Inc John Hancock Mutual John Hancock Mutual-Sheller John Hancock Mutual-Whirlpool John Hancock Mutual - CSA JOHN HANCOCK MUTUAL LIF John Hancock Mutual Life Ins. John Hancock Mutual Life Ins. Kemper National Services Kimberly-Clark Preferred Servr KIRKE-VAN ORSDEL INC. KLAIS & COMPANY, INC. Klais & Company,Inc Liberty Life Auto Club Liberty Mutual Life Care Centers Of America Life Insurance Co. Of Georgia Life Investors Ins. Life Investors Ins. Of America LifeRe Insurance Company Lincoln National Life Line Construction Benefit Fund Logistics Health Inc. Loyal American Life Insurance, Co Macgregor Golf Company Mail Handlers Benefit Plan Managing Underwriters, Inc. March Vision Marco Group Health Plan Marquette National Marquette National Life Insurance Company Marsh Advantage America Marsh Affinity Group MASS MUTUAL MASS. MUTUAL MASSACHUSETTS MUTUAL MASSMUTUAL MASSMUTUAL GROUP CLAIM McDowell Agency,Inc Medica Medicaid Medical Mutual Of Ohio Medicare Medicare - Railroad Medico Life Insurance Co. MEDIGAP # 007379896 MEDIPLUS MEDIPLUS/The Hartford Meritain Health Met Life Met Life-Saturn Health Claims Met Life - Met Life - Sears Met Life -GM MetLife-Guinness American, Inc Metra Health Metrahealth MetraHealth METROPOLITAN (PEPSI CO) Metropolitan Life-American Can Metropolitan Life -Amer. Can METROPOLITAN LIFE INS. Metropolitan Life Ins.-Wilson Metropolitan Life Ins. Co. Metropolitan Life Insurance METROPOLITAN LIFE INSURANCE Middle Tennessee State University Midwest Operating Engineers Midwestern Insurance Alliance Monumental Life Insurance Co. Motion Industries MSC MTMC Employee Health Plan Mutual Of Omaha Mutual Protective/Medico Life NALC Health Benefit Plan NAME National Assoc. Of Carriers National Financial Ins. Co. National Foundation Life Ins. National Group Ins, Co. NATIONAL HOME LIFE CO. NATIONAL LIFE & ACC. NATIONAL STATES INS. National States Insurance National Travelers Life Co Nationwide Insurance Nationwide Insurance Enterpris NATIONWIDE MUTUAL INS. NEA Group Insurance New Era Life Ins New Era Life Insurance Co New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New York Life Ins. Co. Newera Life Insurance Co. NewMarket Dimensions NHC Health Benefit Plan North America Administrators Norwest Financial Novanet/Signature NTCA/SMC-ASHVILLE SER. CENTE OMAHA HEALTH CARE SER. CENTER Opticare Optum Health P M Group Pacific Mutual Life Insurance PALMETTO GOV BENEFITS ADMIN Pan American Life Ins. Co. PAN AMERICAN LIFE INS.C PCS Health Systems Pension Assoc. PHCS Nashville PHCS UMR Philadelphia American Life Phoenix Healthcare Of TN, Inc. PHP TnCare Physicians Mutual Insurance Co PILOT LIFE INSUR. CO. PIONEER LIFE PIONEER LIFE INSURANCE Pioneer Life Insurance Co. PIONEER LIFE INSURANCE CO. Pittman & Assoc, Inc. Pittman & Associates Plumbers & Pipefitters Fund 572 Plummers & Steamfitters Local 43 POMCO Group Postmasters Benefit Plan Preferred Health Partnership Preferred Health Plan, Inc. Principal Life Insurance Co Principal Life Ins. Co. Principal Life Insurance Co Principal Mutual Life Ins. Co. Principle Life Insurance Co. Provident PROVIDENT Provident-Harton Hospital Provident - Nissan Motor Corp. Provident Life &accident Ins Provident Life And Accident Prudential-Rich'S Prudential Ins. Co. PRUDENTIAL INSURANCE CO Pyramid Life Pyramid Life Insurance Co RBMS, LLc Regional West Medical Center Reserve Health Readiness Progr Reserve National Ins. Co. Retirement Plans Office Of SDA Robey-Barber Insurance Serv. Royal Insurance Rural Carrier Benefit Plan SAI A CORESOURCE COMPANY Seabury & Smith, Inc Seafarer's Welfare Plan Security Life Ins Co Shaw Industries Shaw Medical Shaw Medical Claims Accordia Sheet Metal Workers National Sheffield Of Tennessee SHELBYVILLE POWER CO. Shelbyville Power System Shelter Life Insurance Co. Signature Health Signature Health Alliance SmartHealth Southern Electrical Health Fun Southland Benefit Solutions Southland National Insurance Southwest Administrators Spectera-Bell South Unit SRC STANDARD LIFE INS. STANDARD LIFE INSURANCE CO Standard Life Insurance Co. Star HRG Starmark State Farm Health Ins. State Farm Health Insurance State Farm Mutual STATE FARM MUTUAL State Health Benefit Plan STATE MUTUAL CO. STATE OF TENN MEDICAID State Of Tn (Children's Plan) Sterling Option 1 Sterling Option II Sun Healthcare Group, Inc, Superior National Superior Vision Services Teamcare Temtex Products,Inc. TennCare Select Tennessee Healthcare Tennessee Valley Operating Eng THC/MMS The City Of Manchester THE EATON BENEFITS Office The Eaton Benefits Payment Off THE EQUITABLE The Equitable Life Ins. The Farmers Bank The Funds The Guardian The Plan Handlers, Inc The Principal Financial Group The Prudential THE PRUDENTIAL The Prudential Ins. Co. Of Am. The Pyramid Life Ins. Co. The TPA, Inc. The Travelers THE TRAVELERS INS. The Travelers Insurance Co. The Ullico Family Of Companies The Union Labor Life Ins The Union Labor Life Ins. Co. THRG/HNN Tricare Tricare For Life UMR UMWA Health & Retirement Funds Union Bankers United American Insurance Company United Health Care United Healthcare United HealthCare United HealthCare United Healthcare Ins. Co United Healthcare Network, Inc UnitedHealthCare UnitedHealthcare Community Plan UnitedHealthcare Medicare Solutions USAA Life Insurance Co. VCP-Humana Vision Care Direct VSP VSP-Access Plan William C. Beeler And Co. Windsor Medicare Extra Woodmen of the World Young Life Beneftis Plan
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:
Birthday:
SSN:
Employer/School:

Fourth

Insurance Information

Insurance Name:	None A.A.R.P. AARP Accordia National Admiral Life Insurance Co Adventist Risk Management Aerospace Contractors' Trust Aetna Aetna AETNA AETNA-Frito Lay AETNA-JCPenney AETNA-Mail Well Corporation AETNA-Pepsi-Cola AETNA-ROCK-TENN AETNA-Southern TN Medical AETNA Health Plans Of TN, Inc. Aetna Life Insurance Company Aetna US Healthcare AETNA USHC AMA American Contiental Insurance American Family Ins. American Medical Security American National Life Ins American Pioneer American Republic Insurance Co AmeriChoice Amerigroup Ameritus Anthem Blue Cross Blue Sheild APWU Araiza Company Arkansas Blue Cross/Blue Shie ASEA/AFSCME Local 52 Health Benefits Trust Assoication & Society Ins Corp Assurant Health Avesis AVMA Group Health Bankers Fidelity Bankers Life And Casualty BC/BS BlueAdvantage Operations BCBS - Memphis BCBSTN Bench Mark Tool Benesight Blue Cross Blue Sheild Of GA Blue Cross Blue Sheild Of Mich Blue Cross Blue Shield of Texas Blue Cross/ Blue Shield Of Al BLUECARE Brentwood Services Bridgestone Safety BRMS Brown & Brown Benefits CARE Caremark Center Care Central Reserve Life Ins. Co. Central States CHAMPVA Cigna Cigna Cigna Cigna Cigna CIGNA CIGNA Cigna Government Services DME Cigna Health Care Cigna Healthcare City Of Manchester CNA Co-ordinated Benefit Plans, LLC Coast to Coast Vision Colonial Penn Health Insurance Columbia Healthcare Network Combined Insurance Co. Of Amer Commerce Benefits Group Community Care Network Community Health Alliance Comp Benefits(Humana/VCP) Compainion Property & Casualty Complete Health Concordia Health Plan Connecticut General Connecticut General-Avon Connecticut General-Kaman Corp Connecticut General-Stanley Continental General Continental Life Cooperative Benefit Adm CoreSource, Inc. Covenant Adminstrators,Inc Eba&m Equicor ESIS Essilor Safety Family Life Insurance Company Federated Insurance Finlay Industries, Inc. First American First Community Health Plan, Inc First Health Fiserv Health FMH CoreSource Foreign Service Benefit Plan Fortis Benefits Insurance Co. Fortis Insurance Co Freedom Life Insurance Co. of America GEHA General American General American General American General American Life Ins. Co Gerber Life Insurance Golden Rule Insurance Company Goodyear Tire And Rubber Co Great West Life 7 Annuity Group and Pension Administrators Guarantee Trust Life Insurance Co. Guardian GWH-Cigna GWH-Cigna Harrington Harrington/Brookfield Hartford Accident & Indemnity Hartford Life Health Claim Hartford Life Health Claim Off Hartford Life Senior Medical Health 1-2-3 Health 1-2-3 Platinum HEALTH CHOICE, INC. Health Cost Solutions Health Net HEALTH NET Health Net-Stan Mcnabb Health Net - Earl Swensson Health Net - Tenn Care HEALTH NET, INC. Health Partners Health Partners,Inc Health Risk Management, Inc. Healthnet-Pittman & Associates HEALTHNET PROVIDERS HEALTHNET, INC. HealthSCOPE Benefits HealthScoper Benefits, Inc Healthsource-Provident Healthsource - Provident HealthSpring HealthyAdvantage HealthSpring, Inc HHPO Highmark Services Hill Pack Insurance Agency HMO BLUE Hometown Health Network Humana Claims Humana Claims Dept Humana Health Care Hunt & Taylor Ibew-Neca Southwestern Health Ideal Life Insurance Insurance Claims Service Inc Intracorp/Accumed Services Ira A Watson Co. John Alden Life Insurance Co. John Deere Health Plan,Inc John Hancock Mutual John Hancock Mutual-Sheller John Hancock Mutual-Whirlpool John Hancock Mutual - CSA JOHN HANCOCK MUTUAL LIF John Hancock Mutual Life Ins. John Hancock Mutual Life Ins. Kemper National Services Kimberly-Clark Preferred Servr KIRKE-VAN ORSDEL INC. KLAIS & COMPANY, INC. Klais & Company,Inc Liberty Life Auto Club Liberty Mutual Life Care Centers Of America Life Insurance Co. Of Georgia Life Investors Ins. Life Investors Ins. Of America LifeRe Insurance Company Lincoln National Life Line Construction Benefit Fund Logistics Health Inc. Loyal American Life Insurance, Co Macgregor Golf Company Mail Handlers Benefit Plan Managing Underwriters, Inc. March Vision Marco Group Health Plan Marquette National Marquette National Life Insurance Company Marsh Advantage America Marsh Affinity Group MASS MUTUAL MASS. MUTUAL MASSACHUSETTS MUTUAL MASSMUTUAL MASSMUTUAL GROUP CLAIM McDowell Agency,Inc Medica Medicaid Medical Mutual Of Ohio Medicare Medicare - Railroad Medico Life Insurance Co. MEDIGAP # 007379896 MEDIPLUS MEDIPLUS/The Hartford Meritain Health Met Life Met Life-Saturn Health Claims Met Life - Met Life - Sears Met Life -GM MetLife-Guinness American, Inc Metra Health Metrahealth MetraHealth METROPOLITAN (PEPSI CO) Metropolitan Life-American Can Metropolitan Life -Amer. Can METROPOLITAN LIFE INS. Metropolitan Life Ins.-Wilson Metropolitan Life Ins. Co. Metropolitan Life Insurance METROPOLITAN LIFE INSURANCE Middle Tennessee State University Midwest Operating Engineers Midwestern Insurance Alliance Monumental Life Insurance Co. Motion Industries MSC MTMC Employee Health Plan Mutual Of Omaha Mutual Protective/Medico Life NALC Health Benefit Plan NAME National Assoc. Of Carriers National Financial Ins. Co. National Foundation Life Ins. National Group Ins, Co. NATIONAL HOME LIFE CO. NATIONAL LIFE & ACC. NATIONAL STATES INS. National States Insurance National Travelers Life Co Nationwide Insurance Nationwide Insurance Enterpris NATIONWIDE MUTUAL INS. NEA Group Insurance New Era Life Ins New Era Life Insurance Co New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New York Life Ins. Co. Newera Life Insurance Co. NewMarket Dimensions NHC Health Benefit Plan North America Administrators Norwest Financial Novanet/Signature NTCA/SMC-ASHVILLE SER. CENTE OMAHA HEALTH CARE SER. CENTER Opticare Optum Health P M Group Pacific Mutual Life Insurance PALMETTO GOV BENEFITS ADMIN Pan American Life Ins. Co. PAN AMERICAN LIFE INS.C PCS Health Systems Pension Assoc. PHCS Nashville PHCS UMR Philadelphia American Life Phoenix Healthcare Of TN, Inc. PHP TnCare Physicians Mutual Insurance Co PILOT LIFE INSUR. CO. PIONEER LIFE PIONEER LIFE INSURANCE Pioneer Life Insurance Co. PIONEER LIFE INSURANCE CO. Pittman & Assoc, Inc. Pittman & Associates Plumbers & Pipefitters Fund 572 Plummers & Steamfitters Local 43 POMCO Group Postmasters Benefit Plan Preferred Health Partnership Preferred Health Plan, Inc. Principal Life Insurance Co Principal Life Ins. Co. Principal Life Insurance Co Principal Mutual Life Ins. Co. Principle Life Insurance Co. Provident PROVIDENT Provident-Harton Hospital Provident - Nissan Motor Corp. Provident Life &accident Ins Provident Life And Accident Prudential-Rich'S Prudential Ins. Co. PRUDENTIAL INSURANCE CO Pyramid Life Pyramid Life Insurance Co RBMS, LLc Regional West Medical Center Reserve Health Readiness Progr Reserve National Ins. Co. Retirement Plans Office Of SDA Robey-Barber Insurance Serv. Royal Insurance Rural Carrier Benefit Plan SAI A CORESOURCE COMPANY Seabury & Smith, Inc Seafarer's Welfare Plan Security Life Ins Co Shaw Industries Shaw Medical Shaw Medical Claims Accordia Sheet Metal Workers National Sheffield Of Tennessee SHELBYVILLE POWER CO. Shelbyville Power System Shelter Life Insurance Co. Signature Health Signature Health Alliance SmartHealth Southern Electrical Health Fun Southland Benefit Solutions Southland National Insurance Southwest Administrators Spectera-Bell South Unit SRC STANDARD LIFE INS. STANDARD LIFE INSURANCE CO Standard Life Insurance Co. Star HRG Starmark State Farm Health Ins. State Farm Health Insurance State Farm Mutual STATE FARM MUTUAL State Health Benefit Plan STATE MUTUAL CO. STATE OF TENN MEDICAID State Of Tn (Children's Plan) Sterling Option 1 Sterling Option II Sun Healthcare Group, Inc, Superior National Superior Vision Services Teamcare Temtex Products,Inc. TennCare Select Tennessee Healthcare Tennessee Valley Operating Eng THC/MMS The City Of Manchester THE EATON BENEFITS Office The Eaton Benefits Payment Off THE EQUITABLE The Equitable Life Ins. The Farmers Bank The Funds The Guardian The Plan Handlers, Inc The Principal Financial Group The Prudential THE PRUDENTIAL The Prudential Ins. Co. Of Am. The Pyramid Life Ins. Co. The TPA, Inc. The Travelers THE TRAVELERS INS. The Travelers Insurance Co. The Ullico Family Of Companies The Union Labor Life Ins The Union Labor Life Ins. Co. THRG/HNN Tricare Tricare For Life UMR UMWA Health & Retirement Funds Union Bankers United American Insurance Company United Health Care United Healthcare United HealthCare United HealthCare United Healthcare Ins. Co United Healthcare Network, Inc UnitedHealthCare UnitedHealthcare Community Plan UnitedHealthcare Medicare Solutions USAA Life Insurance Co. VCP-Humana Vision Care Direct VSP VSP-Access Plan William C. Beeler And Co. Windsor Medicare Extra Woodmen of the World Young Life Beneftis Plan
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Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
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Medical History

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OCULAR HISTORY

Date of last Comprehensive Exam

with Dr.

S. McBride, OD E. Hoge, OD H. Sohrabi, OD B. Palmer, OD W. Frye, OD P. Patterson, OD J. Blanks, OD A. Bell, OD G. Muse, OD H. Norris, MD C. Collier, MD B. Mahan, MD B. Ebrahim, MD S. Duckworth, OD J. Anderson, OD S. Anderson, OD R. Littell, OD L. Womack, OD M. Hicks, OD K. Woodall, OD E. Eichenberger, OD B. Womble, OD L. Perkins, OD D. Dejarnatt, OD K. Shamblin, OD K. Gregory, OD D. Hasty, OD J. Deharde, OD Other

Age when first prescribed glasses

Do you have lazy eye?	No Right Left Both Other
Have you had treatment for lazy eye, such as patching?	No 2 hours or less/day More than 2 hours/day Atropine drops Other

History of contact lens wear?	Never Current Past Other
Type(s) of contact lenses worn	Disposable Toric Multifocal Monovision Rigid Hybrid Orthokeratology Colored Scleral Custom soft Other
If you have discontinued wearing contact lenses, why?	Discomfort Dryness Inadequate vision Inconvenience Cost Handling Infection Cataract surgery Refractive surgery Other

Current or previous eye or vision issues/diagnoses

Please check any applicable condition and add unlisted conditions to diagnosis summary. Thank you!

Dry Eye Syndrome

Eye Allergies

Blepharitis (eyelid inflammation)

Eyelid Lesion

Cataracts

Eye Turn (Strabismus)

Macular Degeneration

Diabetic Eye Disease

Glaucoma or Glaucoma Susupect

Optic Nerve Disease

Floaters or Spots in Vision

Freckle or Mole

Retinal Hole

Retinal Detachment

Diagnosis Summary:

Have you been prescribed a nutritional supplement for macular degeneration?

Maxivision E&BF Maxivision WBF Maxivision Macula Maxivision Ocular Tozal Preservision AREDS2 Ocuvite ICaps MV ICaps AREDS ICaps L&O3 ICaps L&Z EyePromise Zn-Free Other

List any previous eye injuries or infections
Please list any other past issues about your eyes we should be aware of

Have you ever had any surgeries or procedures involving the eyes or eyelids?       Yes No       If yes, this will be reviewed during your exam



MEDICAL HISTORY

Do you have diabetes?	No Type 2 Type 1 Borderline Gestational Prior Hx Other
If yes, when were you diagnosed?
How is your blood sugar controlled?	Oral meds Insuiln inj. Insulin pump Diet Exercise Not trying Other
What is your most recent blood glucose reading?	Doesn't check Other
When was this reading taken?	This am Last pm Yest. am Other
What was your most recent hemoglobin A1c reading?	Unknown "Good" Other

                  Is your blood sugar currently well-controlled?           Under ControlNot well-controlled

Please list any other medical conditions you are aware of:

Please check any applicable condition and add unlisted conditions to diagnosis summary. Thank you!

Hypertension (High Blood Pressure)

High Cholesterol

Cardiovascular Disease

Heart Rhythm Disorder

Heart Attack/Cardiac Arrest

Blood Disorder

Sinus/Nasal Allergies

Asthma

Chronic Obstructive Pulmonary Disease (COPD)

Emphysema

Arthritis

Sjogren's Syndrome

Thyroid Condition

Lupus

Crohn's Disease

Sarcoidosis

Stroke

Transient Ischemic Attack (TIA or ministroke)

Chronic Headaches

Migraine Headaches

Depression

Anxiety Disorder

Fibromyalgia

Attention Deficit Disorder (ADD/ADHD)

Mental Illness

Alzheimer's Disease

Cancer

Chronic Pain

Diagnosis Summary:

Who is your primary care physician?	Lynette Adams, MD John Anderson, MD Steve Bills, MD Richard Cole, MD Andrea Gore, CFNP Aldo Ilarde, MD Marcus Lee, MD William Milam, MD Rob Nichols, MD Partners for Healing John Patsimas, MD William Sanders, MD Bob Yasui, PA None Other
If you have diabetes, who is the primary physician for this care?	Lynette Adams, MD John Anderson, MD Steve Bills, MD Richard Cole, MD Andrea Gore, CFNP Aldo Ilarde, MD Marcus Lee, MD William Milam, MD Rob Nichols, MD Partners for Healing John Patsimas, MD William Sanders, MD Bob Yasui, PA None Other
What other physicians do you see?	Lynette Adams, MD John Anderson, MD Steve Bills, MD Richard Cole, MD Andrea Gore, CFNP Aldo Ilarde, MD Marcus Lee, MD William Milam, MD Rob Nichols, MD Partners for Healing John Patsimas, MD William Sanders, MD Bob Yasui, PA None Other
For what type of care?	Cardiology Dermatology Endocrinology Gastroenterology Nephrology Neurology Neurosurgery Oncology Urology Other

Have you had allergic reactions to any medications?       Yes No       If yes, this will be reviewed during your exam

Please list your current medications:     NO current medications

What is your preferred local pharmacy?

Baker Bros. - Manchester Bennett's - Winchester Blue Front - Winchester Bradford's - Estill Springs Carter's - Fayetteville Carter's at Stonebridge CVS - Decherd CVS - Shelbyville CVS - Tullahoma Fred's - Decherd Kmart - Tullahoma Kroger - Shelbyville Kroger - Tullahoma Kroger - Winchester Lynchburg Drug Store Marcrom's - Manchester McGee's - Shelbyville Rite Aid - Manchester Rite Aid - Shelbyville Tullahoma Drug Store Walgreens - Manchester Walgreens - Tullahoma Wal-Mart - Shelbyville Wal-Mart - Tullahoma Wal-Mart - Winchester Other

What is your mail-order pharmacy?

Express Scripts Other

Where do you prefer prescriptions for chronic medications to be sent?Local Pharmacy PreferredMail-Order Preferred

Please list any OTC medications you take	None Aspirin Acetomenophin Ibuprofen naproxen Allegra Claritin Zyrtec Benedryl Prilosec Other
Please list any vitamins and/or supplements you take	None Centrum Silver Vit. A Vit. C Vit. D3 Vit. E Iron Zinc Lutein Calcium glucosamine chondroitin Co-Q10 Other
Please list any significant injuries, surgeries, or hospitalizations
Please indicate if you are currently pregnant or nursing	No Yes Unsure Other
Please list any additional notes we should be aware of

SOCIAL HISTORY

What visual demands do you have in your occupation?	Computer use Documents Close detail inspection Night driving Outdoors Public speaking Other
What visual working distances are important in your occupation?	50+ ft. 15-50 ft. 6-15 ft. 3-6 ft. 20-36 in. 14-20 in. less than 14 in. Other
List any environmental issus in your occupation that might impact your eyes	poor lighting bright glare issues dry dusty fumes/vapors cold low humidity humid Other
What visual aids or protection do you use at work?	None Dress glasses Non-Rx Safety Rx Safety Computer glasses Reading glasses Contact lenses Other

Do you drive?

Please list any issues while driving

None Daytime glare Nighttime glare Can't read road signs Can't see dashboard Can't see GPS Problem judging distances Other

Please list any sports, activities or hobbies you engage in	Acting Astronomy Art Baseball Boating Basketball Cooking Crafts Dancing Diving Football Fishing Golf Gardening Horseback Riding Hunting Models Movies Needlepoint Painting Photography Piano Reading Running Roller Blading Softball Sewing Skiing Soccer Social media Swimming Tennis Video Games Woodworking Other	Acting Astronomy Art Baseball Boating Basketball Cooking Crafts Dancing Diving Football Fishing Golf Gardening Horseback Riding Hunting Models Movies Needlepoint Painting Photography Piano Reading Running Roller Blading Softball Sewing Skiing Soccer Social media Swimming Tennis Video Games Woodworking Other	Acting Astronomy Art Baseball Boating Basketball Cooking Crafts Dancing Diving Football Fishing Golf Gardening Horseback Riding Hunting Models Movies Needlepoint Painting Photography Piano Reading Running Roller Blading Softball Sewing Skiing Soccer Social media Swimming Tennis Video Games Woodworking Other	Acting Astronomy Art Baseball Boating Basketball Cooking Crafts Dancing Diving Football Fishing Golf Gardening Horseback Riding Hunting Models Movies Needlepoint Painting Photography Piano Reading Running Roller Blading Softball Sewing Skiing Soccer Social media Swimming Tennis Video Games Woodworking Other
Visual working distances	50+ ft. 15-50 ft. 6-15 ft. 3-6 ft. 20-36 in. 14-20 in. less than 14 in. Other	50+ ft. 15-50 ft. 6-15 ft. 3-6 ft. 20-36 in. 14-20 in. less than 14 in. Other	50+ ft. 15-50 ft. 6-15 ft. 3-6 ft. 20-36 in. 14-20 in. less than 14 in. Other	50+ ft. 15-50 ft. 6-15 ft. 3-6 ft. 20-36 in. 14-20 in. less than 14 in. Other
Visual correction used	None Dress glasses Non-Rx Safety Rx Safety Computer glasses Reading glasses Task-specific glasses Sports goggles Contact lenses Other	None Dress glasses Non-Rx Safety Rx Safety Computer glasses Reading glasses Task-specific glasses Sports goggles Contact lenses Other	None Dress glasses Non-Rx Safety Rx Safety Computer glasses Reading glasses Task-specific glasses Sports goggles Contact lenses Other	None Dress glasses Non-Rx Safety Rx Safety Computer glasses Reading glasses Task-specific glasses Sports goggles Contact lenses Other

Smoking Status

Never smoker (<100 cigs equiv) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Unknown if ever smoked

Do you drink alcoholic beverages?	No Yes Occasionally Socially In past In treatment Other	Type:	None Beer Wine Hard Liquor Other	How Long:
Do you use recreational drugs?	No Yes In past In treatment Other	Type:	marijuana Cocaine Meth Heroin Ecstacy Narcotics Other	How Long:

Do you have any sexually transmitted diseases?

None Gonorrhea Syphilis Hepatitis HIV TB Other

What is your race?	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Patient Declined to Specify Other
What is your ethnicity?	Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Other
What language do you prefer?	English Spanish French Patient Declined to Specify Abkhazian Afar Afrikaans Akan Albanian Amharic Arabic Aragonese Armenian Assamese Avaric Avestan Aymara Azerbaijani Bambara Bashkir Basque Belarusian Bengali Bihari languages Bislama Bokm?l, Norwegian), Norwegian Bokm?l Bosnian Breton Bulgarian Burmese Catalan; Valencian Central Khmer Chamorro Chechen Chichewa; Chewa; Nyanja Chinese Church Slavic; Old Slavonic; Church Slavonic; Old Bulgarian; Old Church Slavonic Chuvash Cornish Corsican Cree Croatian Czech Danish Divehi; Dhivehi; Maldivian Dutch; Flemish Dzongkha Esperanto Estonian Ewe Faroese Fijian Finnish Fulah Gaelic; Scottish Gaelic Galician Ganda Georgian German Greek, Modern (1453-) Guarani Gujarati Haitian; Haitian Creole Hausa Hebrew Herero Hindi Hiri Motu Hungarian Icelandic Ido Igbo Indonesian Interlingua (International Auxiliary Language Association) Interlingue; Occidental Inuktitut Inupiaq Irish Italian Japanese Javanese Kalaallisut; Greenlandic Kannada Kanuri Kashmiri Kazakh Kikuyu; Gikuyu Kinyarwanda Kirghiz; Kyrgyz Komi Kongo Korean Kuanyama; Kwanyama Kurdish Lao Latin Latvian Limburgan; Limburger; Limburgish Lingala Lithuanian Luba-Katanga Luxembourgish; Letzeburgesch Macedonian Malagasy Malay Malay Malayalam Maltese Manx Maori Maori Marathi Marshallese Mongolian Nauru Navajo; Navaho Ndebele, North; North Ndebele Ndebele, South; South Ndebele Ndonga Nepali Northern Sami Norwegian Norwegian Nynorsk; Nynorsk, Norwegian Occitan (post 1500) Ojibwa Oriya Oromo Ossetian; Ossetic Pali Panjabi; Punjabi Persian Polish Portuguese Pushto; Pashto Quechua Romanian; Moldavian), Moldovan Romansh Rundi Russian Samoan Sango Sanskrit Sardinian Serbian Shona Sichuan Yi; Nuosu Sindhi Sinhala; Sinhalese Slovak Slovenian Somali Sotho, Southern Sundanese Swahili Swati Swedish Tagalog Tahitian Tajik Tamil Tatar Telugu Thai Tibetan Tigrinya Tonga (Tonga Islands) Tsonga Tswana Turkish Turkmen Twi Uighur; Uyghur Ukrainian Urdu Uzbek Venda Vietnamese Volap?k Walloon Welsh Western Frisian Wolof Xhosa Yiddish Yoruba Zhuang; Chuang Zulu Other

Review of Systems

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GENERAL: Fever, Weight loss, Weight gain, Fatigue	None Fever Recent weight loss Recent weight gain Fatigue Other
EAR, NOSE, THROAT: Hearing loss, Tinnitus, Nasal allergies, Sinus problems, Cough	None Hearing loss Tinnitus Nasal allergies Sinus Problems Chronic Cough Dry Throat / Mouth Other
CARDIOVASCULAR: High BP, Heart disease, Vascular disease	None High BP Heart disease Vascular Disease Stroke Other
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD	None Asthma Bronchitis Emphysema COPD Other
GENITAL, KIDNEY, BLADDER: Kidney stones, Frequent Urination, Impotence	None Kidney stones Kidney disease Frequent urination Impotence Other
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury	None Rheumatoid arthritis Osteo arthritis Joint pain Joint stiffness Head injury Neck injury Muscle cramps Ankylosing Spondylitis Other
SKIN: Rosacea, Skin cancer, Rash	None Rosacea Skin cancer Vitiligo Rash Nodules Other
NEUROLOGICAL: Headaches, Migraines, Seizures	None Headaches Migraines Numbness Tingling Paralysis Seizures Other
PSYCHIATRIC: Depression, Anxiety, Insomnia	None Depression Anxiety Insomnia Bipolar Other
ENDORCRINE: Diabetes, Thyroid	None Diabetes Hyperthyroid Hypothyroid Other
BLOOD/LYMPH: High cholesterol, Anemia, Bleeding disorder	None High cholesterol Anemia Bleeding disorder Leukemia Other
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux	None Diarrhea Constipation Ulcer Acid Reflux Other
ALLERGIC / IMMUNOLOGIC: Seasonal allergies, Hives, Auto-immune disease, AIDS	None Seasonal allergies Other allergies Hives Auto-immune disease Lupus Sarcoidosis AIDS Other

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