Patient History Form

Demographics

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

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:
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Single Married Separated Divorced Widowed Unknown	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Loomis, Steven Dr. Yount, Kent Dr. Kruchen, Mark Dr. Peterson, Tara Dr. Doctor, Outside	Misc/Guardian

Billing Information

Is The Billing Address the Same?

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

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:

Vision

Insurance Information

Insurance Name:	None AARP United HealthCare Added Choice First Health Network Adventist Risk Management, INC Aetna Aetna Global Benefits Aetna Health Plan-Alaska Care Aetna Life Insurance Company Aetna Medicare Aetna PPO, EPO Allied Benefit Systems, Inc Altius Assoc. Benefit Plan EDI Assurant Health KBA Assurant Health PPO Auxiant AVMA Group Health Life Ins Trust Bankers Life and Casualty Co Bankers Life and Casualty Company BC/BS Federal Employee Program Blue Advantage Blue Advantage HMO Plan Blue Cross Blue Shield Blue Cross Blue Shields Kansas City Blue View Vision Butler Benefit Service, Inc Caremark Carpenters Dist Council of Kansas City& Vicinity Health Plan CEBT Celtic Individual Health Champva Christian Brothers Employee Benefit Trust Cigna Cigna Federal Health Plan CIGNA Government Services Cigna HealthCare PPO Cigna Healthy Rewards Discount Cigna International CIGNA Medicare CIGNA Open Access Cigna PPO CNIC Health Solutions Coast to Coast Cofinity Colorado Blue Cross&Blue Shield Companion Life Compbenefits Visioncare Connecticut General Life Insurance Co Coventry Health Care Cover Colorado Cover Colorado Pacificare Definity Health/United Healthcare Options Developmental Disabilities Resource Center EBMS Empire State Carpenters Welfare Fund Erickson Advantage Evercare United Health Group EyeMed Vision Care EyeMed/ Delta Dental Eyemed/ Mail Handler's Benefit Plan Farmers Insurance First Health Network/HealthSCOPE Benefits First Health/CBSA Performax First Health/MBA of MD, Inc. First Health/Wells Fargo TPA First United American Life Ins Co FISERV Fiserv Health FRA Insurance Plans GEHA GEHA United Healthcare Golden Rule Insurance Company Goldenn Rule Insurance Company GPA Great West Healthcare Group Administrators, Ltd Group Resources Guardian Group Medical Plans Harrington Health HARVARD PILGRIM HEALTHCARE Harvard Pilgrim PPO HCH Administration Health Net Health Net Commercial Claims Health Partners HealthSCOPE Benefits/PHCS Network Highmark Humana Humana Gold Choice IMG Kaiser NP Kaiser Permanente Claims Dept/PHCS Klais and Company, Inc Medicare-Railroad Carrier Medicare Complete MEDICARE PART B MeritaIn Health Meritain Health/PHCS Missionary Medical Morris Associates Motorola Medicare Supplement Plan Mountain State Blue Cross & Blue Shiel Mountain States New Insurance None Oxford United Healthcare Pacificare Trust Preferred One Admin Services Principal Life Ins Co Private Healthcare Systems Professional Benefits Administrators Religious Comprehensive Trust Rocky Mountain Health Plans SBS Sierra Health and Life Sight for Students/VSP Strategic Resource Company Superior Vision Service, Inc The Mail Handlers Benefit Plan The United Healthcare Tricare UMR UMR CEBT UMR PPO UniCare Security Choice United Health Integrated Services United Healthcare United Healthcare Compass Rose Health Plan United Medical Resources United World Life Insurance Company Vision Care Direct Vision Care Provider Network CO Contractors, N. Roofers Health & Wellfare Vision Service Plan Well Fargo Insurance Services World Venture
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:
Employer/School:

Primary Medical

Insurance Information

Insurance Name:	None AARP United HealthCare Added Choice First Health Network Adventist Risk Management, INC Aetna Aetna Global Benefits Aetna Health Plan-Alaska Care Aetna Life Insurance Company Aetna Medicare Aetna PPO, EPO Allied Benefit Systems, Inc Altius Assoc. Benefit Plan EDI Assurant Health KBA Assurant Health PPO Auxiant AVMA Group Health Life Ins Trust Bankers Life and Casualty Co Bankers Life and Casualty Company BC/BS Federal Employee Program Blue Advantage Blue Advantage HMO Plan Blue Cross Blue Shield Blue Cross Blue Shields Kansas City Blue View Vision Butler Benefit Service, Inc Caremark Carpenters Dist Council of Kansas City& Vicinity Health Plan CEBT Celtic Individual Health Champva Christian Brothers Employee Benefit Trust Cigna Cigna Federal Health Plan CIGNA Government Services Cigna HealthCare PPO Cigna Healthy Rewards Discount Cigna International CIGNA Medicare CIGNA Open Access Cigna PPO CNIC Health Solutions Coast to Coast Cofinity Colorado Blue Cross&Blue Shield Companion Life Compbenefits Visioncare Connecticut General Life Insurance Co Coventry Health Care Cover Colorado Cover Colorado Pacificare Definity Health/United Healthcare Options Developmental Disabilities Resource Center EBMS Empire State Carpenters Welfare Fund Erickson Advantage Evercare United Health Group EyeMed Vision Care EyeMed/ Delta Dental Eyemed/ Mail Handler's Benefit Plan Farmers Insurance First Health Network/HealthSCOPE Benefits First Health/CBSA Performax First Health/MBA of MD, Inc. First Health/Wells Fargo TPA First United American Life Ins Co FISERV Fiserv Health FRA Insurance Plans GEHA GEHA United Healthcare Golden Rule Insurance Company Goldenn Rule Insurance Company GPA Great West Healthcare Group Administrators, Ltd Group Resources Guardian Group Medical Plans Harrington Health HARVARD PILGRIM HEALTHCARE Harvard Pilgrim PPO HCH Administration Health Net Health Net Commercial Claims Health Partners HealthSCOPE Benefits/PHCS Network Highmark Humana Humana Gold Choice IMG Kaiser NP Kaiser Permanente Claims Dept/PHCS Klais and Company, Inc Medicare-Railroad Carrier Medicare Complete MEDICARE PART B MeritaIn Health Meritain Health/PHCS Missionary Medical Morris Associates Motorola Medicare Supplement Plan Mountain State Blue Cross & Blue Shiel Mountain States New Insurance None Oxford United Healthcare Pacificare Trust Preferred One Admin Services Principal Life Ins Co Private Healthcare Systems Professional Benefits Administrators Religious Comprehensive Trust Rocky Mountain Health Plans SBS Sierra Health and Life Sight for Students/VSP Strategic Resource Company Superior Vision Service, Inc The Mail Handlers Benefit Plan The United Healthcare Tricare UMR UMR CEBT UMR PPO UniCare Security Choice United Health Integrated Services United Healthcare United Healthcare Compass Rose Health Plan United Medical Resources United World Life Insurance Company Vision Care Direct Vision Care Provider Network CO Contractors, N. Roofers Health & Wellfare Vision Service Plan Well Fargo Insurance Services World Venture
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:
Employer/School:

Secondary Medical

Insurance Information

Insurance Name:	None AARP United HealthCare Added Choice First Health Network Adventist Risk Management, INC Aetna Aetna Global Benefits Aetna Health Plan-Alaska Care Aetna Life Insurance Company Aetna Medicare Aetna PPO, EPO Allied Benefit Systems, Inc Altius Assoc. Benefit Plan EDI Assurant Health KBA Assurant Health PPO Auxiant AVMA Group Health Life Ins Trust Bankers Life and Casualty Co Bankers Life and Casualty Company BC/BS Federal Employee Program Blue Advantage Blue Advantage HMO Plan Blue Cross Blue Shield Blue Cross Blue Shields Kansas City Blue View Vision Butler Benefit Service, Inc Caremark Carpenters Dist Council of Kansas City& Vicinity Health Plan CEBT Celtic Individual Health Champva Christian Brothers Employee Benefit Trust Cigna Cigna Federal Health Plan CIGNA Government Services Cigna HealthCare PPO Cigna Healthy Rewards Discount Cigna International CIGNA Medicare CIGNA Open Access Cigna PPO CNIC Health Solutions Coast to Coast Cofinity Colorado Blue Cross&Blue Shield Companion Life Compbenefits Visioncare Connecticut General Life Insurance Co Coventry Health Care Cover Colorado Cover Colorado Pacificare Definity Health/United Healthcare Options Developmental Disabilities Resource Center EBMS Empire State Carpenters Welfare Fund Erickson Advantage Evercare United Health Group EyeMed Vision Care EyeMed/ Delta Dental Eyemed/ Mail Handler's Benefit Plan Farmers Insurance First Health Network/HealthSCOPE Benefits First Health/CBSA Performax First Health/MBA of MD, Inc. First Health/Wells Fargo TPA First United American Life Ins Co FISERV Fiserv Health FRA Insurance Plans GEHA GEHA United Healthcare Golden Rule Insurance Company Goldenn Rule Insurance Company GPA Great West Healthcare Group Administrators, Ltd Group Resources Guardian Group Medical Plans Harrington Health HARVARD PILGRIM HEALTHCARE Harvard Pilgrim PPO HCH Administration Health Net Health Net Commercial Claims Health Partners HealthSCOPE Benefits/PHCS Network Highmark Humana Humana Gold Choice IMG Kaiser NP Kaiser Permanente Claims Dept/PHCS Klais and Company, Inc Medicare-Railroad Carrier Medicare Complete MEDICARE PART B MeritaIn Health Meritain Health/PHCS Missionary Medical Morris Associates Motorola Medicare Supplement Plan Mountain State Blue Cross & Blue Shiel Mountain States New Insurance None Oxford United Healthcare Pacificare Trust Preferred One Admin Services Principal Life Ins Co Private Healthcare Systems Professional Benefits Administrators Religious Comprehensive Trust Rocky Mountain Health Plans SBS Sierra Health and Life Sight for Students/VSP Strategic Resource Company Superior Vision Service, Inc The Mail Handlers Benefit Plan The United Healthcare Tricare UMR UMR CEBT UMR PPO UniCare Security Choice United Health Integrated Services United Healthcare United Healthcare Compass Rose Health Plan United Medical Resources United World Life Insurance Company Vision Care Direct Vision Care Provider Network CO Contractors, N. Roofers Health & Wellfare Vision Service Plan Well Fargo Insurance Services World Venture
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:
Employer/School:

Medical History

How did you hear about us?
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PERSONAL VISUAL HISTORY

Wears Glasses (GL)	Wears Contact Lenses (CL)	Hours/day on Computer	Had Punctal Plugs in Past
Full-time	Soft	Symptoms from Comp. Use	Has Punctal Plugs
Part-time	RGP	Eye Diseases or Conditions	Interested in Lasik?
GL Purpose	Full-time	Eye Injuries	Interested in CLs?
Have backup GLs?	Part-time	Eye Surgeries	Dry, gritty, burning eyes?
	How often/Purpose?	Major Surgeries or Illneses

 

 

 

 

 

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PERSONAL MEDICAL HISTORY

MEDICAL ALLERGIES   

CURRENT MEDS & DROPS (PRESCRIPTION &  OVER THE COUNTER)	TAKEN FOR (REASON/DISEASE/CONDITION):

 

 

 

 

 

 

 

 

 

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REVIEW OF SYSTEMS

Pregnant or nursing? Yes No      Due Date
 

Kids - Birth/Developmental History:

General:

Ears, Nose, Throat:

Cardiovascular:

Respiratory:

Genital, Kidney, Bladder:

Muscles, Bones, Joints:

Skin:

Neurological:

Psychiatric:

Endocrine:

Blood/Lymph:

Allergic/Immunologic

      
      
   

 

 

 

 

 

 

 

  

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FAMILY MEDICAL HISTORY

Adopted	Lazy Eye (Amblyopia) Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Blindness Mother Father Sister Brother Aunt Uncle Grandmother Grandfather	Glaucoma Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Cataracts Mother Father Sister Brother Aunt Uncle Grandmother Grandfather	High Blood Pressure Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Diabetes   Mother Father Sister Brother Aunt Uncle Grandmother Grandfather	Macular Degeneration Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Eye turn (Strabismus) Mother Father Sister Brother Aunt Uncle Grandmother Grandfather	Other Inherited Disease Mother Father Sister Brother Aunt Uncle Grandmother Grandfather

 

 
 
 

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SOCIAL HISTORY
Do you smoke/use tobacco products? Never Occasionally Daily Past Smoker   Do you drink alcohol? Occasional Never Frequently

HIPAA

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