Online Patient Form

Demographics

Patient Information

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

Address:
City:		State/ZipCode	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 TN UT VT VI VA WA WV WI WY

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Text Message Cell Phone Email Work Phone Home Phone Other Phone
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		Drivers License #

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Billing Information

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

Copy Address From Above
Address

City	State	ZipCode
	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 TN UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None New Insurance New Insurance AETNA ALTA HEALTH STRATEGIES AMERICAN GENERAL FINANCE AMERICAN INS. ADMINISTARORS AMERICAN INSURANCE ADMIN Assurant Health AVP VISION PLANS BLUE CROSS BLUE SHIELD CARPENTER S HEALTH WELFARE CCN CIGNA CORE SOURCE CVS Caremark DELTA HEALTH SYSTEMS DEPARTMENT OF REHABILITATION ECPA EMPLOYEE BENEFIT ADMINISTRATOR EYE MED FIRST HEALTH GBBA GREAT WEST HEALTH NET PPO HEALTHCOMP HUMANA I C SYSTEMS INC LLUAHSC LUMENOS MEDI CAL MEDICAL EYE SERVICES OF CALIF MEDICARE Medicare/ Railroad NALC HEALTH BENEFIT PLAN NAVA CONSTRUCTION BATT. CENTER ORANGE COUNTY EMPLOYEES ASSO PACIFIC COAST ADMINISTRATORS PACIFICARE PRUDENTIAL RETAIL CLERKS Risk Management RLI INSURANCE COMPANY Significa STATE COMPENSATION TITAN SPECTRON TRICARE U S ADMINISTRATORS UNICARE UNITED HEALTHCARE UPS VISION SERVICE PLAN VISIONCARE VISIONET WESTERN BENEFITS ADMINISTRATOR
Insurance 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 New Insurance New Insurance AETNA ALTA HEALTH STRATEGIES AMERICAN GENERAL FINANCE AMERICAN INS. ADMINISTARORS AMERICAN INSURANCE ADMIN Assurant Health AVP VISION PLANS BLUE CROSS BLUE SHIELD CARPENTER S HEALTH WELFARE CCN CIGNA CORE SOURCE CVS Caremark DELTA HEALTH SYSTEMS DEPARTMENT OF REHABILITATION ECPA EMPLOYEE BENEFIT ADMINISTRATOR EYE MED FIRST HEALTH GBBA GREAT WEST HEALTH NET PPO HEALTHCOMP HUMANA I C SYSTEMS INC LLUAHSC LUMENOS MEDI CAL MEDICAL EYE SERVICES OF CALIF MEDICARE Medicare/ Railroad NALC HEALTH BENEFIT PLAN NAVA CONSTRUCTION BATT. CENTER ORANGE COUNTY EMPLOYEES ASSO PACIFIC COAST ADMINISTRATORS PACIFICARE PRUDENTIAL RETAIL CLERKS Risk Management RLI INSURANCE COMPANY Significa STATE COMPENSATION TITAN SPECTRON TRICARE U S ADMINISTRATORS UNICARE UNITED HEALTHCARE UPS VISION SERVICE PLAN VISIONCARE VISIONET WESTERN BENEFITS ADMINISTRATOR
Insurance 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 New Insurance New Insurance AETNA ALTA HEALTH STRATEGIES AMERICAN GENERAL FINANCE AMERICAN INS. ADMINISTARORS AMERICAN INSURANCE ADMIN Assurant Health AVP VISION PLANS BLUE CROSS BLUE SHIELD CARPENTER S HEALTH WELFARE CCN CIGNA CORE SOURCE CVS Caremark DELTA HEALTH SYSTEMS DEPARTMENT OF REHABILITATION ECPA EMPLOYEE BENEFIT ADMINISTRATOR EYE MED FIRST HEALTH GBBA GREAT WEST HEALTH NET PPO HEALTHCOMP HUMANA I C SYSTEMS INC LLUAHSC LUMENOS MEDI CAL MEDICAL EYE SERVICES OF CALIF MEDICARE Medicare/ Railroad NALC HEALTH BENEFIT PLAN NAVA CONSTRUCTION BATT. CENTER ORANGE COUNTY EMPLOYEES ASSO PACIFIC COAST ADMINISTRATORS PACIFICARE PRUDENTIAL RETAIL CLERKS Risk Management RLI INSURANCE COMPANY Significa STATE COMPENSATION TITAN SPECTRON TRICARE U S ADMINISTRATORS UNICARE UNITED HEALTHCARE UPS VISION SERVICE PLAN VISIONCARE VISIONET WESTERN BENEFITS ADMINISTRATOR
Insurance 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:

Chief Complaint

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

CHIEF COMPLAINT	Blur distance vision blurry near vision blurry vision blurry distance and near red eye pain in eye loss of vision injury to eye needs new glasses wants to be fitted for contacts itching burning stinging dry eyes Diabetic eye exam Other
Secondary Complaints:

REVIEW OF OCULAR SYSTEM: Injuries, Infections, Surgeries, Diseases

None Itching Burning, Stinging Amblyopia Eye Injuries Eye Surgery Flashes Of Light Floaters Strabismus Cataracts Glaucoma Retinal Disorders Other

Eye Meds:

None Visine Patanol Xalatan Travatan rewetting drops Elestat Vigamox Alphagan Refresh Theratears Genteal Pred Forte Lotemax Alrex Systane Blink Other

Last Eye Exam:

1 year 2 years 3 years Other

Doctor:

Morrison Cullinane Doesn't Remember Never Other

Family Eye History

Glaucoma:	No Parents Sibling Grandparent Other	Cataracts:	No Parents Siblings Grandparent Other
Macular Degen:	No Parents Siblings Grandparent Other	Retinal Detach:	No Parents Siblings Grandparent Other
Crossed / Lazy:	No Parents Siblings Grandparent Other

Previous Vision Correction

Primary Vision Correction:	None Glasses-Full Time Glasses-Readers Only Contacts - Soft RGPs Glasses- Distance only Other	Planning to get new glasses?	Yes No Other	Back up specs?	Yes No Other
Type of CLs worn in past:	None Colored RGP Disposable Other	Wear Time:	None 8 - 10 Hours All day Occ. Overnight Extended Other	Cleaner:	None Optifree Clear Care Boston Renu Other
Disposal:	None 2 weeks monthly daily weekly yearly Other

Preferred Language:

English French German Spanish Other

Race

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander Other Race Patient Declined to Specify White Other

Ethnicity

Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Other

Medical History

PATIENT MEDICAL HISTORY: HAs, Arthritis, Asthma, Diabetes, HBP, Heart, Infl. Bowel Dz, Seizures, Thyroid

Good health Arthritis Asthma Diabetes HBP Headaches Heart Condition HX Of Drug/Alcohol Abuse Inflammatory Bowel Disease Smoking Seizure Disorder Thyroid Disease Preg Now Nursing Diagnosed As HIV+ High Cholesterol Other	Diabetes HBP Heart disease Cancer Arthritis Lupus Kidney Thyroid Back Problems Other	Athritis Diabetes HBP Heart Disease Cancer Lupus Kidney Disease Thyroid Disease Back Problems Other
Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Thyroid Back Problems Other	Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Thyroid Disease Back Problems Other	Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Disease Thyroid Back Problems Other

Injuries, Surgeries, Hospitalization

Pregnant Or Nursing:

No Yes Unsure Other

Recent Tetanus Shot:

Yes No Other

Primary Care Physcian:

None Doesn't Have One Doesn't Remember Other

Last Visit:

1 week 1 month 3 months 6 months 1 year 2 years Other

Reason For Visit:

Check up Annual Other

OTC:

None Asprin Acetomenophin Ibuprofen Other

Vitamins:

None A E C Zinc Xanten Lutein Other

FAMILY MEDICAL HISTORY: Diabetes, HBP, Heart Dz, Cancer, Athritis, Lupus, Kidney, Thyroid, Other

None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid Other

Occupation:

Student Retired Other

Hobbies:

Baseball Basketball Crafts Dancing Football Fishing Golf Gardening Horseback Riding Hunting Needlepoint None Painting Photography Piano Reading Running Softball Sewing Skiing Soccer Swimming Tennis Video Games Woodworking Other

Smoking Status	Current every day smoker Current some day smoker (not daily) Former smoker (no longer smokes) Heavy smoker (>10 cigs/day) Light smoker (<10 cigs/day) Never smoker (<100 cigs equiv) Smoker (current status unknown) Unknown if ever smoked Other	Type:	None Cigaretts Chewing Tobacco Other	How Long:
Alcohol:	No Yes Occasionally Socially Other	Type:	None Beer Wine Hard Liquor Other	How Long:
Illegal Drugs:	No Yes Other	Type:		How Long:
STD:	None Gonorrhea Syphilis Hepatitis HIV TB Other

Review Of Systems

Do You Currently Have Any Of These Problems?

GENERAL: Fever, weight loss, weight gain, fatigue?	None Negative Other
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat	None Allergies Sinus Problems Chronic Cough Dry Throat / Mouth Hard of Hearing Other
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease	None High BP Surgery Vascular Disease Other
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD	None Asthma Bronchitis Emphysema COPD Other
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence	None painful urination frequent urination impotence yellow jaundice Other
MUSCLES, BONES, JOINTS: Athritis, Joint Pains, Head or Neck Injury	None joint pain stiffness swelling cramps arthritis Other
SKIN: growths, rashes, acne	None pimples, warts growths rash Other
NEUROLOGICAL: Headaches, migraines, seizures	None numbness, paralysis headache seizures migraines Other
PSYCHIATRIC: Depression, Anxiety, Insomnia	None anxiety depression insomnia Other
ENDORCRINE: Thyroid, Diabetes	None diabetes hypothyroid hyperthoyroid Other
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems	None bleeding cholestrolemia anemia Other
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus	None sneezing swelling redness itching hives lupus Other
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux	None Diarrhea Constipation Ulcer Acid Reflux Other

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