Patient Form
Demographics
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:
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
Single
Married
Separated
Divorced
Widowed
Unknown
Employer/School Name
Primary Doctor
No Doctor Assigned
Dr. Montemayor, Roland G.
Dr. Schaub, David S.
Dr. Spragins, Beth
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
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
ADVANTICA BENEFITS
AETNA
ALWAYS CARE
AMERITAS EYE
AVESIS
BC/BS
BLOCK VISION- COMMERCIAL
BLOCK VISION- MEDICAID
CHEVRON
CIGNA
COAST 2COAST
DAVIS VISION
EVERCARE
EVERCARE TX
EXXON
EYE MED
GREAT WEST
HEALTH FIRST TPA
HUMANA
MES
NVA
OPTUM
OUTLOOK
PACIFIC CARE
PLUMBERS LOCAL UNION #68
SAFEGUARD
SELF-PAY
SIGHT FOR STUDENTS
ST. JOHN VINEY CHURCH
SUPERIOR
TEXAS REHABILITATION COMMISSION
TRUE VISION
TSO DISCOUNT
UNITED HEALTH CARE
VCP
VSP- ACCESS PLAN
VSP-CHOICE PLAN
VSP-SIGNATURE PLAN
WELLCARE
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
ADVANTICA BENEFITS
AETNA
ALWAYS CARE
AMERITAS EYE
AVESIS
BC/BS
BLOCK VISION- COMMERCIAL
BLOCK VISION- MEDICAID
CHEVRON
CIGNA
COAST 2COAST
DAVIS VISION
EVERCARE
EVERCARE TX
EXXON
EYE MED
GREAT WEST
HEALTH FIRST TPA
HUMANA
MES
NVA
OPTUM
OUTLOOK
PACIFIC CARE
PLUMBERS LOCAL UNION #68
SAFEGUARD
SELF-PAY
SIGHT FOR STUDENTS
ST. JOHN VINEY CHURCH
SUPERIOR
TEXAS REHABILITATION COMMISSION
TRUE VISION
TSO DISCOUNT
UNITED HEALTH CARE
VCP
VSP- ACCESS PLAN
VSP-CHOICE PLAN
VSP-SIGNATURE PLAN
WELLCARE
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
ADVANTICA BENEFITS
AETNA
ALWAYS CARE
AMERITAS EYE
AVESIS
BC/BS
BLOCK VISION- COMMERCIAL
BLOCK VISION- MEDICAID
CHEVRON
CIGNA
COAST 2COAST
DAVIS VISION
EVERCARE
EVERCARE TX
EXXON
EYE MED
GREAT WEST
HEALTH FIRST TPA
HUMANA
MES
NVA
OPTUM
OUTLOOK
PACIFIC CARE
PLUMBERS LOCAL UNION #68
SAFEGUARD
SELF-PAY
SIGHT FOR STUDENTS
ST. JOHN VINEY CHURCH
SUPERIOR
TEXAS REHABILITATION COMMISSION
TRUE VISION
TSO DISCOUNT
UNITED HEALTH CARE
VCP
VSP- ACCESS PLAN
VSP-CHOICE PLAN
VSP-SIGNATURE PLAN
WELLCARE
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:
Medical History
Diabetes
HBP
Heart Disease
Cancer
Arthritis
Lupus
Kidney Disease
Thyroid
Back Problems
Diabetes
HBP
Heart Disease
Cancer
Arthritis
Lupus
Kidney
Thyroid Disease
Back Problems
Diabetes
HBP
Heart Disease
Cancer
Arthritis
Lupus
Kidney
Thyroid
Back Problems
Athritis
Diabetes
HBP
Heart Disease
Cancer
Lupus
Kidney Disease
Thyroid Disease
Back Problems
Diabetes
HBP
Heart disease
Cancer
Arthritis
Lupus
Kidney
Thyroid
Back Problems
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+
medhx6 medhx5 medhx4 Problems:
medhx2
medhx3
None
Injuries, Surgeries, Hospitalization
Yes
No
No
Yes
Unsure
Notes: Recent Tetanus Shot: Pregnant Or Nursing:
Check up
Annual
1 week
1 month
3 months
6 months
1 year
2 years
Doesn't Have One
Doesn't Remember
Reason For Visit: Last Visit: Primary Care Physcian:
None
A
E
C
Zinc
Xanten
Lutein
None
Asprin
Acetomenophin
Ibuprofen
NKDA
No current meds
Vitamins: OTC:
None
Adopted
Diabetes
HBP
Cancer
Cardiovascular Disease
Athritis
Kidney Disease
Lupus
Thyroid
fmh6
fmh4 fmh3
fmh5
fmh2
Astronomy
Art
Baseball
Boating
Basketball
Cooking
Crafts
Dancing
Diving
Football
Fishing
Golf
Gardening
Horseback Riding
Hunting
Models
Needlepoint
None
Painting
Photography
Piano
Reading
Running
Roller Blading
Softball
Sewing
Skiing
Soccer
Swimming
Tennis
Video Games
Woodworking
Student
Police officer
Teacher
Nurse
Salesman
Firefighter
Engineer
Hobbies: Occupation:
Never Smoker
Current every day smoker
Current some day smoker
Former smoker
Smoker, currernt status unknown
Unknown if ever smoked
None
Cigaretts
Chewing Tobacco
How Long: Type: Smoking Status:
No
Yes
Occasionally
Socially
None
Beer
Wine
Hard Liquor
How Long: Type: Alcohol:
No
Yes
None
Gonorrhea
Syphilis
Hepatitis
HIV
TB
STD: How Long: Type: Illegal Drugs:
Submit Data
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