Nuevo formulario Paciente

Demografía

Título Primero MI Apellido Sufijo Apodo Sr. Sra. Srta. Dr. Rdo. Fr.

Dirección: Ciudad: Estado/Código Postal 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

Teléfono de Casa: Teléfono del Trabajo: Otro Teléfono: Teléfono Móvil: Método de Contacto Preferido: Teléfono de Casa Teléfono del Trabajo Teléfono Móvil Otro Teléfono Mensaje de Texto Email SSN Email Cumpleaños Ocupación Género Masculino Hembra Estado de Empleo Empleado Estudiante a tiempo completo Estudiante de medio tiempo Estado Civil Anulado Divorciado Socio Doméstico Interlocutorio Legalmente Separado Casado Soltero Polígamo Viudo Empleador/Colegio Nombre Guardián

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Titulo	Primero	Apellido	MI	Sufijo
Sr. Sra. Srta. Dr. Rdo. Fr.

Dirección

Ciudad	Estado	Código Postal
	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

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Primario

Información del Seguro

Nombre de Seguros:	Ninguna 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 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
Identificación de Seguro:
Grupo póliza de Seguro:

No primario en cuenta: No Primaria

Primaria en Cuenta

Nombre:	Apellido, Primero, MI
Relación:	Esposa Niño Otro
Sex:	Masculino Hembra
Dirección:
Ciudad: Estado: Código Postal:
Número de Teléfono:
Cumpleaños:
SSN:
Empleador/Colegio:

Secundario

Información del Seguro

Nombre de Seguros:	Ninguna 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 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
Identificación de Seguro:
Grupo póliza de Seguro:

No primario en cuenta: No Primaria

Primaria en Cuenta

Nombre:	Apellido, Primero, MI
Relación:	Esposa Niño Otro
Sex:	Masculino Hembra
Dirección:
Ciudad: Estado: Código Postal:
Número de Teléfono:
Cumpleaños:
SSN:
Empleador/Colegio:

Terciario

Información del Seguro

Nombre de Seguros:	Ninguna 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 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
Identificación de Seguro:
Grupo póliza de Seguro:

No primario en cuenta: No Primaria

Primaria en Cuenta

Nombre:	Apellido, Primero, MI
Relación:	Esposa Niño Otro
Sex:	Masculino Hembra
Dirección:
Ciudad: Estado: Código Postal:
Número de Teléfono:
Cumpleaños:
SSN:
Empleador/Colegio:

Cuaternario

Información del Seguro

Nombre de Seguros:	Ninguna 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 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
Identificación de Seguro:
Grupo póliza de Seguro:

No primario en cuenta: No Primaria

Primaria en Cuenta

Nombre:	Apellido, Primero, MI
Relación:	Esposa Niño Otro
Sex:	Masculino Hembra
Dirección:
Ciudad: Estado: Código Postal:
Número de Teléfono:
Cumpleaños:
SSN:
Empleador/Colegio:

Historial Médico

Elija entre las opciones del menú o seleccionar "Otros" para escribir en múltiples opciones y/o su propio texto. ¡Gracias!


HISTORIA DE OJOS

Fecha de la última examen completo de:

Con 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

Edad en la primera gafas prescritas:

¿Tiene el ojo perezoso?:	No Derecha Izquierda Ambos Otro
¿Ha tenido tratamiento para el ojo vago, tales como parches?	No 2 horas o menos al día Más de 2 horas al día gotas de atropina Otro

Historia de lentes de contacto?	Nunca Presente Pasado Otro
Tipo de lentes de contacto desgastada:	Desechable Tórico Multifocal Monovisión Rígido Híbrido Ortoqueratología De Colores Escleral Custom Suave Otro
Si ha dejado de usar lentes de contacto, ¿por qué?	Incomodidad Aridez Visión inadecuada Inconveniencia Costo Manejo Infección Cirugía de cataratas La cirugía refractiva Otro

Problemas oculares o de visión actual o anterior/diagnósticos

Por favor verifique en cualquier condición aplicable y añadir condiciones no cotizados al resumen del diagnóstico. ¡Gracias!

Síndrome del ojo seco

Las alergias oculares

La inflamación de los párpados

La lesión del párpado

Las cataratas

Encienda el ojo

Degeneración Macular

Enfermedad diabética del ojo

Glaucoma o sospecha de glaucoma

Enfermedades del Nervio Óptico

Flotadores o manchas en la visión

Peca o lunar

Agujero de la retina

Desprendimiento de retina

Diagnóstico Resumen:

¿Se le ha recetado un suplemento nutricional para la degeneración macular?

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 Otro

Enumerar las lesiones oculares o infecciones anteriores:
Por favor liste cualquier otra cuestión últimos sobre sus ojos hay que tener en cuenta:

¿Ha tenido alguna cirugía o procedimientos que involucren los ojos o los párpados?       Sí No       Si es así, será objeto de revisión durante el examen.



HISTORIAL MÉDICO

¿Tienes diabetes?	No Tipo 2 Tipo 1 Límite Gestacional Historia previa Otro
En caso afirmativo, cuando fue diagnosticado?
¿Cómo se controla el nivel de azúcar en la sangre?	Medicamentos orales La inyección de insulina Bomba de insulina Dieta Ejercicio No tratar Otro
¿Cuál es su lectura má reciente de glucosa en la sangre?	No comprueba Otro
Cuando se tomó esta lectura?	Esta mañana Anoche Ayer por la mañana Otro
¿Cuál fue su lectura más reciente de hemoglobina A1c ?	Desconocido "Bueno" Otro

                  Actualmente está bien controlada su azúcar en la sangre?           Bajo controlNo bien controlada

Por favor liste cualquier otra condición médica que está al tanto de:

Por favor verifique en cualquier condición aplicable y añadir condiciones no cotizados al resumen del diagnóstico. ¡Gracias!

Hipertensión (Alta presion sanguinea)

Colesterol alto

Enfermedad cardiovascular

Trastorno del Ritmo Cardiaco

Ataque del corazón/Paro cardiaco

Desorden sanguineo

Sinusal o alergias nasales

Asma

Enfermedad pulmonar obstructiva crónica (EPOC)

Enfisema

Artritis

Síndrome de Sjogren

Condición de tiroides

Lupus

Enfermedad de Crohn

Sarcoidosis

Accidente cerebrovascular"

Ataque isquémico transitorio

Los dolores de cabeza crónicos

Migrañas

Depresión

Trastorno de Ansiedad

La fibromialgia

Desorden de déficit de atención (ADD/ADHD)

Enfermedad mental

La enfermedad de Alzheimer

Cáncer

Dolor crónico

Diagnóstico Resumen:

¿Quién es su médico de atención primaria?	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 Ninguna Otro
Si usted tiene diabetes, que es el médico de cabecera para este servicio?	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 Ninguna Otro
¿Qué otros médicos es lo que ves?	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 Ninguna Otro
Para qué tipo de atención?	Cardiología Dermatología Endocrinología Gastroenterología Nefrología Neurología Neurocirugía Oncología Urología Otro

¿Ha tenido reacciones alérgicas a los medicamentos?       Sí No       Si es así , serí objeto de revisión durante el examen

Por favor, una lista de sus medicamentos actuales:     NO medicamentos actuales

¿Cuál es su farmacia local preferido?

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 Otro

¿Cuál es su farmacia de pedidos por correo?

Express Scripts Otro

¿Dónde prefiere recetas de medicación crónica para ser enviados?Farmacia Preferida LocalEl pedido por correo Preferido

Por favor, indique cualquier más de los medicamentos que toma:	Ninguna Aspirina Acetomenophin Ibuprofeno Naproxeno Allegra Claritin Zyrtec Benedryl Prilosec Otro
Por favor liste cualquier tipo de vitaminas y/o suplementos que toma:	Ninguna Centrum Silver Vit. A Vit. C Vit. D3 Vit. E Iron Zinc Lutein Calcio Glucosamina Condroitina Co-Q10 Otro
Por favor liste cualquier importantes lesiones, cirugías u hospitalizaciones:
Por favor indique si está embarazada o amamantando:	No Sí Inseguro Otro
Por favor enumerar las notas adicionales que debemos tener en cuenta:

HISTORIA SOCIAL

Lo que exige la visual tiene usted en su ocupación?	Ninguna El uso del ordenador Documentos Detalle cercano de inspección La conducción nocturna Trabajo al aire libre Hablar en público Otro
Lo distancias de trabajo visuales son importantes en su ocupación?	Ninguna 50+ ft. 15-50 ft. 6-15 ft. 3-6 ft. 20-36 in. 14-20 in. menos que 14 in. Otro
Una lista de cualquier issus del medio ambiente en su trabajo que pueda afectar a sus ojos:	Ninguna Mala iluminación Luz brillante Deslumbramiento Seco Polvoriento Humos/Vapores Frío Baja humedad Alta humedad Otro
¿Qué ayudas o de protección visual utiliza usted en el trabajo?	Ninguna Gafas de vestir Vidrios de seguridad no sujetos a prescripción Gafas graduadas de seguridad Gafas de equipo Gafas de lectura Lentes de contacto Otro

¿Manejas?

Por favor anote cualquier problema durante la conducción:

Ninguna El resplandor diurno Deslumbramiento nocturno No se puede leer las señales de tráfico No se puede ver cuadro de mandos No se puede ver GPS Problema juzgar distancias Otro

Por favor liste cualquier deporte, las actividades o pasatiempos que lleves a cabo:	Ninguna Interino Astronomía Art Béisbol Paseo en barco Baloncesto Cocina Artesanía Bailando Buceo Fútbol americano Fútbol Pescar Golf Jardinería Montar a caballo Caza Modelos Películas Punto del aguja Pintura Fotografía Piano Leyendo Corriendo Blading Sofbol De coser Esquiar Medios de comunicación social Nadando Tenis Videojuegos Tratamiento de la madera Otro	Ninguna Interino Astronomía Art Béisbol Paseo en barco Baloncesto Cocina Artesanía Bailando Buceo Fútbol americano Fútbol Pescar Golf Jardinería Montar a caballo Caza Modelos Películas Punto del aguja Pintura Fotografía Piano Leyendo Corriendo Blading Sofbol De coser Esquiar Medios de comunicación social Nadando Tenis Videojuegos Tratamiento de la madera Otro	Ninguna Interino Astronomía Art Béisbol Paseo en barco Baloncesto Cocina Artesanía Bailando Buceo Fútbol americano Fútbol Pescar Golf Jardinería Montar a caballo Caza Modelos Películas Punto del aguja Pintura Fotografía Piano Leyendo Corriendo Blading Sofbol De coser Esquiar Medios de comunicación social Nadando Tenis Videojuegos Tratamiento de la madera Otro	Ninguna Interino Astronomía Art Béisbol Paseo en barco Baloncesto Cocina Artesanía Bailando Buceo Fútbol americano Fútbol Pescar Golf Jardinería Montar a caballo Caza Modelos Películas Punto del aguja Pintura Fotografía Piano Leyendo Corriendo Blading Sofbol De coser Esquiar Medios de comunicación social Nadando Tenis Videojuegos Tratamiento de la madera Otro
Distancias de trabajo visuales:	Ninguna 50+ ft. 15-50 ft. 6-15 ft. 3-6 ft. 20-36 in. 14-20 in. menos que 14 in. Otro	Ninguna 50+ ft. 15-50 ft. 6-15 ft. 3-6 ft. 20-36 in. 14-20 in. menos que 14 in. Otro	Ninguna 50+ ft. 15-50 ft. 6-15 ft. 3-6 ft. 20-36 in. 14-20 in. menos que 14 in. Otro	Ninguna 50+ ft. 15-50 ft. 6-15 ft. 3-6 ft. 20-36 in. 14-20 in. menos que 14 in. Otro
Visual de corrección utilizado:	Ninguna Gafas de vestir Vidrios de seguridad no sujetos a prescripción Gafas graduadas de seguridad Gafas de equipo Gafas de lectura Gafas para tareas específicas Gafas deportivas Lentes de contacto Otro	Ninguna Gafas de vestir Vidrios de seguridad no sujetos a prescripción Gafas graduadas de seguridad Gafas de equipo Gafas de lectura Gafas para tareas específicas Gafas deportivas Lentes de contacto Otro	Ninguna Gafas de vestir Vidrios de seguridad no sujetos a prescripción Gafas graduadas de seguridad Gafas de equipo Gafas de lectura Gafas para tareas específicas Gafas deportivas Lentes de contacto Otro	Ninguna Gafas de vestir Vidrios de seguridad no sujetos a prescripción Gafas graduadas de seguridad Gafas de equipo Gafas de lectura Gafas para tareas específicas Gafas deportivas Lentes de contacto Otro

Estado de fumadores:

Nunca fumador Ex fumador (ya no fuma) Corriente algún día fumador (no todos los días) Fumador leve Fumador cronico Fumador (desconocido estado actual) No lo sé

¿Consume bebidas alcohólicas?	No Sí De vez en cuando Socialmente En el pasado En tratamiento Otro	Tipo:	Ninguna Cerveza Vino Licor fuerte Otro	Cuánto tiempo:
¿Usa drogas recreativas?	No Sí En el pasado En tratamiento Otro	Tipo:	marijuana Cocaína Metanfetamina Heroína Éxtasis Narcóticos Otro	Cuánto tiempo:

¿Tiene alguna enfermedad de transmisión sexual?

Ninguna Gonorrea SÍfilis Hepatitis VIH Tuberculosis Otro

¿Cuál es su raza?	Indio Americano o Nativo de Alaska Asiático Afroamericano Nativo de Hawai o Otras islas del PacÍfico Caucásico Otro No querer especificar
¿Cuál es su origen étnico?	Hispano o Latino No Hispano o Latino Desconocido No querer especificar
¿Qué idioma prefiere?	Inglés Español Francés No querer especificar 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

Revisión de Sistemas

Elija entre las opciones del menú o seleccionar "Otros" para escribir en múltiples opciones y/o su propio texto. ¡Gracias!

GENERAL: fiebre, pérdida de peso, aumento de peso, fatiga	Ninguna Fiebre Pérdida de peso reciente La ganancia de peso reciente Fatiga Otro
OREJA/NARIZ/GARGANTA: La pérdida de audición, tinnitus alergias, nasales, problemas de sinusitis, tos	Ninguna La pérdida de audición Tinnitus Las alergias nasales Los problemas del sino Tos crónica Garganta seca Otro
CARDIOVASCULAR: Alta presion sanguinea, Enfermedad del corazón, Enfermedad vascular	Ninguna Alta presion sanguinea Enfermedad del corazón Enfermedad Vascular Carrera Otro
RESPIRATORIO: Asma, Bronquitis, Enfisema, EPOC	Ninguna Asma Bronquitis Enfisema EPOC Otro
GENITAL/RIÑÓN/VEJIGA: Cálculos renales, Micción frecuente, Impotencia	Ninguna Cálculos renales Enfermedad del riñón Micción frecuente Impotencia Otro
MÚSCULOS/HUESOS/JUNTAS: Artritis, Dolores en las articulaciones, Lesión en el cuello o la cabeza	Ninguna Artritis reumatoide La osteoartritis Dolores en las articulaciones Rigidez de las articulaciones Lesión craneal Lesión en el cuello Calambres musculares Espondilitis anquilosante Otro
PIEL: La rosácea, Cáncer de piel, Erupción	Ninguna La rosácea Cáncer de piel Vitiligo Erupción Nódulos Otro
NEUROLÓGICO: Los dolores de cabeza, Las migrañas, Convulsiones	Ninguna Los dolores de cabeza Las migrañas Numbness Tingling Paralysis Convulsiones Otro
PSIQUIÁTRICO: Depresión, Ansiedad, Insomnio	Ninguna Depresión Ansiedad Insomnio Bipolar Otro
ENDOCRINO: Diabetes, Tiroides	Ninguna Diabetes Hipertiroidismo Hipotiroidismo Otro
SANGRE/LINFA: Colesterol alto, Anemia, Desorden sangrante	Ninguna Colesterol alto Anemia Desorden sangrante Leucemia Otro
GASTROINTESTINAL: Diarrea, Estreñimiento, Úlcera, Reflujo ácido	Ninguna Diarrea Estreñimiento Úlcera Reflujo ácido Otro
ALÉRGICO/INMUNOLÓGICA: Las alergias estacionales, Urticaria, Enfermedad autoinmune, SIDA	Ninguna Las alergias estacionales Otras alergias Urticaria Enfermedad autoinmune Lupus Sarcoidosis SIDA Otro

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