Patient Form

STEP 1--Demographics

PLEASE FILL OUT OR UPDATE EVERY APPLICABLE FIELD PLEASE USE PROPER CAPITALIZATION Title First Last MI Suffix Nickname Mr. Master Mrs. Ms. Miss Dr. Rev. Jr. Sr. III IV

Address:
City:		State/ZipCode	IL 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:
Cell Phone:
Work Phone:
Other Phone:
Email
Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
Birthday (mm/dd/yyyy)
Sex	Male Female
Marital Status	Never Married Married Widowed Divorced Legally Separated Annulled Domestic partner Interlocutory Polygamous
Employment Status	Employed Full-Time Student Part-Time Student
Occupation
Employer/School Name
Parent/Guardian	(only if under 18 or have a power of attorney)

Billing Information

Check box if The Billing Address is the Same

Title	First	Last	MI	Suffix
Mr. Master Mrs. Ms. Miss Dr. Rev.				Jr. Sr. III IV

Address

City	State	ZipCode
	IL 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:

STEP 2--Vision Insurance

Insurance Information

Insurance Name:	None *SELF PAY* AAA Discount AARP Discount AARP Medicare Supplement/Fixed Indemnity by UHC AARP MedicareComplete though UnitedHealthcare Acordia National Aetna Health Plans Aetna Vision One Discount Plan Aflac Allied National AMA Insurance American Continental Insurance American Medical Security American Republic American Retirement Life Insurance Americo Ameritas Group Claims Auxiant Avesis(OUT OF NETWORK) Bankers Fidelity Bankers Fidelity BAS Blue Cross and Blue Shield of Illinois Blue Cross Blue Shield--Caterpillar Vision Blue Cross Blue Shield HMO (NOT IN NETWORK) Blue Cross Community Options Blue Cross Medicare Advantage- Eligibility Only Blue Cross Medicare Advantage - IL BoonChapman Bridgestone Claims Services Care Improvement Plus Caremark Central Laborers' Welfare Fund Central States Health and Welfare Fund Central United Life Champva - HAC Cigna Combined Insurance Company of America Connecticut General Life Ins. Conseco Consociate Constitution Life Insurance Company Contigo -Bridgestone Claim Processing CoreSource MD, PA, IL Country Companies Coventry Health Care National Network CSI Medical Davis Vision--OUT OF NETWORK, NO OUT OF NETWORK BENEFITS Definity Health Elite Administration Equitable Life & Casualty Insurance Company Everence Eyemed BCBS of IL DISCOUNT EYEMED Vision Care FCE Benefits Administrators First Health Fore Thought Life Ins. CO. Further G.E. Vision Benefits Claim Center Golden Rule Insurance Company Government Employees Hospital Association (GEHA) Great-West Insurance Group Administrators Ltd. Group Plan Solutions Guarantee Trust HCH ADMINISTRATION Health Alliance Health Design Plus Health Partners Health Scope Healthlink Open Access Healthsmart Benefit Solutions Heartland Healthcare Fund Heartland National Life Insurance Company Humana Health Plan Humana Medicaid (NOT IN NETWORK) Humana Military (Tricare East) Humana Vision Care Plan IL Dept. Of Family Services Illinois Partnership of Health Illinois Public Risk Fund Indiana State Council of Roofers Health & Welfare IPMG John Deere Health Plan, Inc. KSKJ Life Land of Lincoln Health Liberty Bankers Life Lincoln Heritage LOCAL 705 I.B of T Health and Welfare Fund Loyal Amerian Loyal Christian Benefit Association Manhattan Life Insurance Company Mayo Clinic Health Solutions Medical Mutual of Ohio Medicare of Illinois Medico Meridian Health Plan of Illinois Meritain Health MetLife MetLife--AGT MetLife--AT&T MetLife--General Motors Mid Central Operating Engineer Midwest Operating Engineers Midwest Security Admn.Inc Molina Healthcare Monumental Life Insurance Mutual Medical Plans, Inc. Mutual Of Omaha National Assoc of Letter Carriers Health Benefit Plan National Elivator Industry Health Benefit Plan NECA-IBEW NRECA Optum Oxford Life Insurance Company Painters District 30 Welfare Fund Pan American Life PBA PCHS Pekin Life Insurance Co. Pennsylvania BCBS Perennial Personal Care Physicians' Benefits Trust Physicians Mutual Insurance Principal Life Insurance Co. Progressive Benefits Services Pyramid Life Insurance Company QualChoice Quartz Railroad Medicare (Augusta, GA) Regence Life & Health Reliance Standard Life Insurance Reserve National RNA Secure Horizons SecureOne Benefit Administrators Security Health Plan Security Life Insurance Company of America Sheet Metal Workers SIHO Insurance Services Spectara--OUT OF NETWORK, NO OUT OF NETWORK BENEFITS Standard Life Insurance Company State Farm Sterling Sterling Investors Suburban Teamsters of Northern IL Welfare Fund Superior Vision Plan The Prudential Thrivent Financial Tricare for Life Tristar Benefit Administrators UFCW UFCWU/EMHBF UMR/Midwest Securities Unicare United American Ins Co United HealthCare of all states United Security USAA Life Insurance USPS FEP Referral Discount Vision Service Plan (VSP) Washington National Wausau Insurance Companies/UHIS WEB-TPA Wellcare Health Plans, Inc. Wellmark Health Network Wells Fargo Third Party Administrators, Inc. Western and Southern Financial Group Benefits Dept Western United Life White Consolidated Indeustries WISBA ZELIS-Auxiant
Insurance ID Number:
Insurance Group Number:

Check if you are not the primary person on the account: Not Primary

Primary on Account

Name:	Last, First MI
Patient's Relationship to Member:	Spouse Child Other
Member's Sex:	Male Female
Member's Address:
City: State: Zip:
Member's Phone Number:
Member's Birthday:
Member's Employer:

STEP 3--Medical Insurance

Insurance Information

Insurance Name:	None *SELF PAY* AAA Discount AARP Discount AARP Medicare Supplement/Fixed Indemnity by UHC AARP MedicareComplete though UnitedHealthcare Acordia National Aetna Health Plans Aetna Vision One Discount Plan Aflac Allied National AMA Insurance American Continental Insurance American Medical Security American Republic American Retirement Life Insurance Americo Ameritas Group Claims Auxiant Avesis(OUT OF NETWORK) Bankers Fidelity Bankers Fidelity BAS Blue Cross and Blue Shield of Illinois Blue Cross Blue Shield--Caterpillar Vision Blue Cross Blue Shield HMO (NOT IN NETWORK) Blue Cross Community Options Blue Cross Medicare Advantage- Eligibility Only Blue Cross Medicare Advantage - IL BoonChapman Bridgestone Claims Services Care Improvement Plus Caremark Central Laborers' Welfare Fund Central States Health and Welfare Fund Central United Life Champva - HAC Cigna Combined Insurance Company of America Connecticut General Life Ins. Conseco Consociate Constitution Life Insurance Company Contigo -Bridgestone Claim Processing CoreSource MD, PA, IL Country Companies Coventry Health Care National Network CSI Medical Davis Vision--OUT OF NETWORK, NO OUT OF NETWORK BENEFITS Definity Health Elite Administration Equitable Life & Casualty Insurance Company Everence Eyemed BCBS of IL DISCOUNT EYEMED Vision Care FCE Benefits Administrators First Health Fore Thought Life Ins. CO. Further G.E. Vision Benefits Claim Center Golden Rule Insurance Company Government Employees Hospital Association (GEHA) Great-West Insurance Group Administrators Ltd. Group Plan Solutions Guarantee Trust HCH ADMINISTRATION Health Alliance Health Design Plus Health Partners Health Scope Healthlink Open Access Healthsmart Benefit Solutions Heartland Healthcare Fund Heartland National Life Insurance Company Humana Health Plan Humana Medicaid (NOT IN NETWORK) Humana Military (Tricare East) Humana Vision Care Plan IL Dept. Of Family Services Illinois Partnership of Health Illinois Public Risk Fund Indiana State Council of Roofers Health & Welfare IPMG John Deere Health Plan, Inc. KSKJ Life Land of Lincoln Health Liberty Bankers Life Lincoln Heritage LOCAL 705 I.B of T Health and Welfare Fund Loyal Amerian Loyal Christian Benefit Association Manhattan Life Insurance Company Mayo Clinic Health Solutions Medical Mutual of Ohio Medicare of Illinois Medico Meridian Health Plan of Illinois Meritain Health MetLife MetLife--AGT MetLife--AT&T MetLife--General Motors Mid Central Operating Engineer Midwest Operating Engineers Midwest Security Admn.Inc Molina Healthcare Monumental Life Insurance Mutual Medical Plans, Inc. Mutual Of Omaha National Assoc of Letter Carriers Health Benefit Plan National Elivator Industry Health Benefit Plan NECA-IBEW NRECA Optum Oxford Life Insurance Company Painters District 30 Welfare Fund Pan American Life PBA PCHS Pekin Life Insurance Co. Pennsylvania BCBS Perennial Personal Care Physicians' Benefits Trust Physicians Mutual Insurance Principal Life Insurance Co. Progressive Benefits Services Pyramid Life Insurance Company QualChoice Quartz Railroad Medicare (Augusta, GA) Regence Life & Health Reliance Standard Life Insurance Reserve National RNA Secure Horizons SecureOne Benefit Administrators Security Health Plan Security Life Insurance Company of America Sheet Metal Workers SIHO Insurance Services Spectara--OUT OF NETWORK, NO OUT OF NETWORK BENEFITS Standard Life Insurance Company State Farm Sterling Sterling Investors Suburban Teamsters of Northern IL Welfare Fund Superior Vision Plan The Prudential Thrivent Financial Tricare for Life Tristar Benefit Administrators UFCW UFCWU/EMHBF UMR/Midwest Securities Unicare United American Ins Co United HealthCare of all states United Security USAA Life Insurance USPS FEP Referral Discount Vision Service Plan (VSP) Washington National Wausau Insurance Companies/UHIS WEB-TPA Wellcare Health Plans, Inc. Wellmark Health Network Wells Fargo Third Party Administrators, Inc. Western and Southern Financial Group Benefits Dept Western United Life White Consolidated Indeustries WISBA ZELIS-Auxiant
Insurance ID Number:
Insurance Group Number:

Check if you are not the primary person on the account: Not Primary

Primary on Account

Name:	Last, First MI
Patient's Relationship to Member:	Spouse Child Other
Member's Sex:	Male Female
Member's Address:
City: State: Zip:
Member's Phone Number:
Member's Birthday:
Member's Employer:

STEP 4--Secondary Insurance

Insurance Information

Insurance Name:	None *SELF PAY* AAA Discount AARP Discount AARP Medicare Supplement/Fixed Indemnity by UHC AARP MedicareComplete though UnitedHealthcare Acordia National Aetna Health Plans Aetna Vision One Discount Plan Aflac Allied National AMA Insurance American Continental Insurance American Medical Security American Republic American Retirement Life Insurance Americo Ameritas Group Claims Auxiant Avesis(OUT OF NETWORK) Bankers Fidelity Bankers Fidelity BAS Blue Cross and Blue Shield of Illinois Blue Cross Blue Shield--Caterpillar Vision Blue Cross Blue Shield HMO (NOT IN NETWORK) Blue Cross Community Options Blue Cross Medicare Advantage- Eligibility Only Blue Cross Medicare Advantage - IL BoonChapman Bridgestone Claims Services Care Improvement Plus Caremark Central Laborers' Welfare Fund Central States Health and Welfare Fund Central United Life Champva - HAC Cigna Combined Insurance Company of America Connecticut General Life Ins. Conseco Consociate Constitution Life Insurance Company Contigo -Bridgestone Claim Processing CoreSource MD, PA, IL Country Companies Coventry Health Care National Network CSI Medical Davis Vision--OUT OF NETWORK, NO OUT OF NETWORK BENEFITS Definity Health Elite Administration Equitable Life & Casualty Insurance Company Everence Eyemed BCBS of IL DISCOUNT EYEMED Vision Care FCE Benefits Administrators First Health Fore Thought Life Ins. CO. Further G.E. Vision Benefits Claim Center Golden Rule Insurance Company Government Employees Hospital Association (GEHA) Great-West Insurance Group Administrators Ltd. Group Plan Solutions Guarantee Trust HCH ADMINISTRATION Health Alliance Health Design Plus Health Partners Health Scope Healthlink Open Access Healthsmart Benefit Solutions Heartland Healthcare Fund Heartland National Life Insurance Company Humana Health Plan Humana Medicaid (NOT IN NETWORK) Humana Military (Tricare East) Humana Vision Care Plan IL Dept. Of Family Services Illinois Partnership of Health Illinois Public Risk Fund Indiana State Council of Roofers Health & Welfare IPMG John Deere Health Plan, Inc. KSKJ Life Land of Lincoln Health Liberty Bankers Life Lincoln Heritage LOCAL 705 I.B of T Health and Welfare Fund Loyal Amerian Loyal Christian Benefit Association Manhattan Life Insurance Company Mayo Clinic Health Solutions Medical Mutual of Ohio Medicare of Illinois Medico Meridian Health Plan of Illinois Meritain Health MetLife MetLife--AGT MetLife--AT&T MetLife--General Motors Mid Central Operating Engineer Midwest Operating Engineers Midwest Security Admn.Inc Molina Healthcare Monumental Life Insurance Mutual Medical Plans, Inc. Mutual Of Omaha National Assoc of Letter Carriers Health Benefit Plan National Elivator Industry Health Benefit Plan NECA-IBEW NRECA Optum Oxford Life Insurance Company Painters District 30 Welfare Fund Pan American Life PBA PCHS Pekin Life Insurance Co. Pennsylvania BCBS Perennial Personal Care Physicians' Benefits Trust Physicians Mutual Insurance Principal Life Insurance Co. Progressive Benefits Services Pyramid Life Insurance Company QualChoice Quartz Railroad Medicare (Augusta, GA) Regence Life & Health Reliance Standard Life Insurance Reserve National RNA Secure Horizons SecureOne Benefit Administrators Security Health Plan Security Life Insurance Company of America Sheet Metal Workers SIHO Insurance Services Spectara--OUT OF NETWORK, NO OUT OF NETWORK BENEFITS Standard Life Insurance Company State Farm Sterling Sterling Investors Suburban Teamsters of Northern IL Welfare Fund Superior Vision Plan The Prudential Thrivent Financial Tricare for Life Tristar Benefit Administrators UFCW UFCWU/EMHBF UMR/Midwest Securities Unicare United American Ins Co United HealthCare of all states United Security USAA Life Insurance USPS FEP Referral Discount Vision Service Plan (VSP) Washington National Wausau Insurance Companies/UHIS WEB-TPA Wellcare Health Plans, Inc. Wellmark Health Network Wells Fargo Third Party Administrators, Inc. Western and Southern Financial Group Benefits Dept Western United Life White Consolidated Indeustries WISBA ZELIS-Auxiant
Insurance ID Number:
Insurance Group Number:

Check if you are not the primary person on the account: Not Primary

Primary on Account

Name:	Last, First MI
Patient's Relationship to Member:	Spouse Child Other
Member's Sex:	Male Female
Member's Address:
City: State: Zip:
Member's Phone Number:
Member's Birthday:
Member's Employer:

STEP 5--Medical History

PATIENT MEDICAL HISTORY
Please select any problems you may have from the drop downs below (select one per box, add your own to the last box if not listed).
Good health Diabetes Hypertension (High Blood Pressure) High Cholesterol Heart Disease Thyroid Disease Kidney Disease Lupus Arthritis Asthma Cancer COPD Back Problems Headaches Inflammatory Bowel Disease Seizure Disorder History of Drug/Alcohol Abuse Diabetes Hypertension (High Blood Pressure) High Cholesterol Heart Disease Thyroid Disease Kidney Disease Lupus Arthritis Asthma Cancer COPD Back Problems Headaches Inflammatory Bowel Disease Seizure Disorder History of Drug/Alcohol Abuse Diabetes Hypertension (High Blood Pressure) High Cholesterol Heart Disease Thyroid Disease Kidney Disease Lupus Arthritis Asthma Cancer COPD Back Problems Headaches Inflammatory Bowel Disease Seizure Disorder History of Drug/Alcohol Abuse Diabetes Hypertension (High Blood Pressure) High Cholesterol Heart Disease Thyroid Disease Kidney Disease Lupus Arthritis Asthma Cancer COPD Back Problems Headaches Inflammatory Bowel Disease Seizure Disorder History of Drug/Alcohol Abuse Diabetes Hypertension (High Blood Pressure) High Cholesterol Heart Disease Thyroid Disease Kidney Disease Lupus Arthritis Asthma Cancer COPD Back Problems Headaches Inflammatory Bowel Disease Seizure Disorder History of Drug/Alcohol Abuse
Please list any Injuries, Surgeries, and/or Hospitalizations
Height feet inches
Weight pounds
Are you Pregnant Or Nursing?: No Yes Unsure
Have you had a Tetanus Shot within the past 5 years?: Yes No
Did you receive this year's flu shot?: Yes No
Primary Care Physcian: Dr. Last Visit: 1 week 1 month 3 months 6 months 1 year 2 years Over 2 years Reason For Visit: Check up Annual Illness
Please list any Vitamins you take:
Please list any Over-The-Counter Medications:
Please list your current Prescription Medications (including doses): No Current Medications
Please list all drug allergies: No Known Drug Allergies
ANSWER THIS LINE ONLY IF DIABETIC -- Last Blood Sugar Reading: When Taken? this AM yesterday within past week 1 week to 1 month ago over 1 month ago Last HbA1C Reading: When Taken? within past month 1 month ago 2 months ago 3 months ago 4 months ago 5 months ago 6 months ago over 6 months ago,
ANSWER THIS LINE ONLY IF DIABETIC -- What Year Were You Diagnosed With Diabetes?
Occupation:
Hobbies:
Smoking Status: Never Smoker (<100 lifetime 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 Smokeless tobacco user Type: None Cigarettes E-Cigarette Chewing Tobacco Cigar Pipe How Long:
Alcohol Use: No Yes Occasionally Socially Rarely Type: None Beer Wine Hard Liquor How Long:
Illegal Drug Use: No Yes Type: None Marijuana Cocaine Heroin Methamphetamine How Long:
History of STD: None Gonorrhea Syphilis Hepatitis HIV TB
Preferred Language: English French German Spanish  Ethnicity:  Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify  Race:  American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Patient Declined to Specify
 

FAMILY MEDICAL HISTORY (Please answer each one)
Please select your closest blood relative from the drop downs below for any relevant condition (plese select None if not relevant).

Diabetes: None Natural Father Natural Mother Natural Brother Natural Sister Half Brother Half Sister Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Paternal Uncle Paternal Aunt Maternal Uncle Maternal Aunt Paternal Cousin Maternal Cousin Nephew Niece Son Daughter Grandson Granddaughter Adopted	Hypertension: None Natural Father Natural Mother Natural Brother Natural Sister Half Brother Half Sister Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Paternal Uncle Paternal Aunt Maternal Uncle Maternal Aunt Paternal Cousin Maternal Cousin Nephew Niece Son Daughter Grandson Granddaughter Adopted
High Cholesterol: None Natural Father Natural Mother Natural Brother Natural Sister Half Brother Half Sister Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Paternal Uncle Paternal Aunt Maternal Uncle Maternal Aunt Paternal Cousin Maternal Cousin Nephew Niece Son Daughter Grandson Granddaughter Adopted	Heart Disease: None Natural Father Natural Mother Natural Brother Natural Sister Half Brother Half Sister Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Paternal Uncle Paternal Aunt Maternal Uncle Maternal Aunt Paternal Cousin Maternal Cousin Nephew Niece Son Daughter Grandson Granddaughter Adopted
Thyroid Disease: None Natural Father Natural Mother Natural Brother Natural Sister Half Brother Half Sister Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Paternal Uncle Paternal Aunt Maternal Uncle Maternal Aunt Paternal Cousin Maternal Cousin Nephew Niece Son Daughter Grandson Granddaughter Adopted	Kidney Disease: None Natural Father Natural Mother Natural Brother Natural Sister Half Brother Half Sister Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Paternal Uncle Paternal Aunt Maternal Uncle Maternal Aunt Paternal Cousin Maternal Cousin Nephew Niece Son Daughter Grandson Granddaughter Adopted
Lupus: None Natural Father Natural Mother Natural Brother Natural Sister Half Brother Half Sister Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Paternal Uncle Paternal Aunt Maternal Uncle Maternal Aunt Paternal Cousin Maternal Cousin Nephew Niece Son Daughter Grandson Granddaughter Adopted	Arthritis: None Natural Father Natural Mother Natural Brother Natural Sister Half Brother Half Sister Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Paternal Uncle Paternal Aunt Maternal Uncle Maternal Aunt Paternal Cousin Maternal Cousin Nephew Niece Son Daughter Grandson Granddaughter Adopted
Asthma: None Natural Father Natural Mother Natural Brother Natural Sister Half Brother Half Sister Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Paternal Uncle Paternal Aunt Maternal Uncle Maternal Aunt Paternal Cousin Maternal Cousin Nephew Niece Son Daughter Grandson Granddaughter Adopted	Cancer: None Natural Father Natural Mother Natural Brother Natural Sister Half Brother Half Sister Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Paternal Uncle Paternal Aunt Maternal Uncle Maternal Aunt Paternal Cousin Maternal Cousin Nephew Niece Son Daughter Grandson Granddaughter Adopted
COPD: None Natural Father Natural Mother Natural Brother Natural Sister Half Brother Half Sister Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Paternal Uncle Paternal Aunt Maternal Uncle Maternal Aunt Paternal Cousin Maternal Cousin Nephew Niece Son Daughter Grandson Granddaughter Adopted	Back Problems: None Natural Father Natural Mother Natural Brother Natural Sister Half Brother Half Sister Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Paternal Uncle Paternal Aunt Maternal Uncle Maternal Aunt Paternal Cousin Maternal Cousin Nephew Niece Son Daughter Grandson Granddaughter Adopted
Headaches: None Natural Father Natural Mother Natural Brother Natural Sister Half Brother Half Sister Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Paternal Uncle Paternal Aunt Maternal Uncle Maternal Aunt Paternal Cousin Maternal Cousin Nephew Niece Son Daughter Grandson Granddaughter Adopted	Inflammatory Bowel Disease: None Natural Father Natural Mother Natural Brother Natural Sister Half Brother Half Sister Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Paternal Uncle Paternal Aunt Maternal Uncle Maternal Aunt Paternal Cousin Maternal Cousin Nephew Niece Son Daughter Grandson Granddaughter Adopted
Seizure Disorder: None Natural Father Natural Mother Natural Brother Natural Sister Half Brother Half Sister Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Paternal Uncle Paternal Aunt Maternal Uncle Maternal Aunt Paternal Cousin Maternal Cousin Nephew Niece Son Daughter Grandson Granddaughter Adopted

PATIENT OCULAR HISTORY
Please select if you have or had any of the following symptoms (please select yes, no, or unsure for every question):

Blurry Distance Vision No Yes Unsure	Blurry Near Vision No Yes Unsure
Cataracts No Yes Unsure	Macular Degeneration No Yes Unsure
Glaucoma No Yes Unsure	Retinal Detachment No Yes Unsure
Retinal Disease/Disorder No Yes Unsure	Amblyopia (Lazy Eye) No Yes Unsure
Strabismus (Eye Turn) No Yes Unsure	Dryness No Yes Unsure
Redness No Yes Unsure	Burning/Stinging No Yes Unsure
Itching No Yes Unsure	Excess tearing/watering eyes No Yes Unsure
Sandy/Gritty feeling No Yes Unsure	Glare/Light sensitivity No Yes Unsure
Mucous discharge No Yes Unsure	Tired eyes No Yes Unsure
Night Vision Problems No Yes Unsure	Flashes of Light No Yes Unsure
Floaters No Yes Unsure	Color Vision Problems No Yes Unsure
Distorted Vision/Halos No Yes Unsure	Double Vision No Yes Unsure
Drooping Eyelid No Yes Unsure	Chronic Eye Infections No Yes Unsure
Eye Pain No Yes Unsure	Sties/Chalazion No Yes Unsure
Prominant Eyes No Yes Unsure	Loss of Side Vision No Yes Unsure

Are your symptoms related to the following environmental conditions?
Windy conditions Yes No, Places with low humidity (e.g. airplanes, hospitals) Yes No, Areas that are air conditioned/heated Yes No

Do you use?

Nutritional supplements (e.g. flaxseed/fish oil, omega-3) Yes No	Contact lenses Yes No
Over-the-counter eye drops such as artificial tears Yes No	Prescription eye drops for Dry Eye Syndrome (e.g. Restasis) Yes No
Prescription eye drops for Glaucoma (e.g. Xalatan, Timolol) Yes No	Prescription or over-the-counter eye drops for Allergy (e.g. Pataday, Alaway) Yes No

Are you taking any of the following medications?

Antihistamines / decongestants (Benadryl, Claritin, Zyrtec, Allegra, Sudafed) Yes No	Antidepressents or anti-anxiety (Paxil, Prosac, Xanax, etc.) Yes No
Oral corticosteroids (Prednisone, etc.) Yes No	Hormone replacement therapy or estrogen (Premarin, etc.) Yes No
Antihypertensives / blood pressure (e.g. diuretic, beta-blockers) Yes No	Accutane or other oral treatment for acne Yes No

Have you ever been diagnosed with Dry Eye Disease or Ocular Surface Disease? Yes No Unsure,

Have you ever had punctal occlusion (punctal plugs)? Yes No Unsure

Have you had or are you considering Refractive Surgery (LASIK)? Yes No Unsure

Please list your current Eye Medications
Last Eye Doctor: Brtva Wetzler Jensen Vize Mayginnes All About Eyes Pearl Doesn't Remember Wal Mart Eyeglass World Stanton Optical America's Best Another LensCrafters Other Last Eye Exam: 1 year 2 years 3 years 4 years 5+ years
Primary Vision Correction:  None Glasses-Full Time Glasses-Near Only Glasses-Distance Only Contacts - Soft Contacts - Hard / Gas Permeable
Are you planning to get new glasses?  Yes No Maybe
Do you have back up glasses?  Yes No
Brand of Contacts currently wearing / worn in the past, Right Eye: None 1 Day Acuvue Moist 1 Day Acuvue Moist for Astigmatism 1 Day Acuvue TruEye Acuvue Oasys Acuvue Oasys for Astigmatism Acuvue Oasys for Presbyopia Acuvue 2 Acuvue Advance Plus Acuvue Advance for Astigmatism Air Optix Aqua Air Optix Aqua Multifocal Air Optix Aqua Night & Day Air Optix for Astigmatism Air Optix Colors Avaira Avaira Toric Biofinity Biofinity Multifocal Biofinity Toric Biotrue ONEday Biotrue ONEday For Presbyopia Clarity 1 Day Disposable Sphere Clarity 1 Day Disposable Multifocal Clarity 1 Day Disposable Toric Clearsight 1 Day Clearsight 1 Day Toric Dailies Aqua Comfort Plus Dailies Aqua Comfort Plus Multifocal Dailies Aqua Comfort Plus Toric Dailies Total1 Extreme H2O Focus Dailies Focus Dailies Progressives Focus Dailies Toric Focus Monthly Softcolors Freshlook Freshlook Toric Proclear Proclear 1 Day Proclear EP Proclear Multifocal Proclear Multifocal XR Proclear Toric Proclear Toric Multifocal Proclear Toric XR Purevision Purevision Multifocal Purevison Toric Purevision 2 HD Purevision 2 for Astigmatism Purevision 2 for Presbyopia SofLens Multifocal SofLens OneDay SofLens Toric Ultra Vertex Vertex Toric Vertex Toric XR Other
Brand of Contacts currently wearing / worn in the past, Left Eye: None 1 Day Acuvue Moist 1 Day Acuvue Moist for Astigmatism 1 Day Acuvue TruEye Acuvue Oasys Acuvue Oasys for Astigmatism Acuvue Oasys for Presbyopia Acuvue 2 Acuvue Advance Plus Acuvue Advance for Astigmatism Air Optix Aqua Air Optix Aqua Multifocal Air Optix Aqua Night & Day Air Optix for Astigmatism Air Optix Colors Avaira Avaira Toric Biofinity Biofinity Multifocal Biofinity Toric Biotrue ONEday Biotrue ONEday For Presbyopia Clarity 1 Day Disposable Sphere Clarity 1 Day Disposable Multifocal Clarity 1 Day Disposable Toric Clearsight 1 Day Clearsight 1 Day Toric Dailies Aqua Comfort Plus Dailies Aqua Comfort Plus Multifocal Dailies Aqua Comfort Plus Toric Dailies Total1 Extreme H2O Focus Dailies Focus Dailies Progressives Focus Dailies Toric Focus Monthly Softcolors Freshlook Freshlook Toric Proclear Proclear 1 Day Proclear EP Proclear Multifocal Proclear Multifocal XR Proclear Toric Proclear Toric Multifocal Proclear Toric XR Purevision Purevision Multifocal Purevison Toric Purevision 2 HD Purevision 2 for Astigmatism Purevision 2 for Presbyopia SofLens Multifocal SofLens OneDay SofLens Toric Ultra Vertex Vertex Toric Vertex Toric XR Other
Wear Time:  Over 12 hours per day 8-12 hours per day Overnight 1-2 nights per week Overnight most nights
Contact solution used: Clear Care Opti-Free RevitaLens Renu / Biotrue Equate Store Brand Boston
How often do you sleep in contacts?: Never Few times per year 1-2 times per month 1-2 times per week 3 or more times per week
How happy are you with your current contacts?: Very happy Somewhat happy Neither happy or unhappy Somewhat unhappy Very unhappy
How often do you replace your CL's?: daily weekly 2 weeks monthly quarterly yearly
What type of sun protection do you wear? None Prescription Sunglasses Non-Prescription Sunglasses Transitions/PhotoGrey
When are you bothered by glare: Never In the sun On computer Night driving Fluorescent lighting  

FAMILY OCULAR HISTORY (Please answer each one. Select closest relative if more than one.)

Glaucoma: None Natural Father Natural Mother Natural Brother Natural Sister Half Brother Half Sister Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Paternal Uncle Paternal Aunt Maternal Uncle Maternal Aunt Paternal Cousin Maternal Cousin Nephew Niece Son Daughter Grandson Granddaughter Adopted	Crossed / Lazy Eye: None Natural Father Natural Mother Natural Brother Natural Sister Half Brother Half Sister Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Paternal Uncle Paternal Aunt Maternal Uncle Maternal Aunt Paternal Cousin Maternal Cousin Nephew Niece Son Daughter Grandson Granddaughter Adopted
Retinal Detachment: None Natural Father Natural Mother Natural Brother Natural Sister Half Brother Half Sister Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Paternal Uncle Paternal Aunt Maternal Uncle Maternal Aunt Paternal Cousin Maternal Cousin Nephew Niece Son Daughter Grandson Granddaughter Adopted	Macular Degeneration: None Natural Father Natural Mother Natural Brother Natural Sister Half Brother Half Sister Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Paternal Uncle Paternal Aunt Maternal Uncle Maternal Aunt Paternal Cousin Maternal Cousin Nephew Niece Son Daughter Grandson Granddaughter Adopted
Cataracts: None Natural Father Natural Mother Natural Brother Natural Sister Half Brother Half Sister Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Paternal Uncle Paternal Aunt Maternal Uncle Maternal Aunt Paternal Cousin Maternal Cousin Nephew Niece Son Daughter Grandson Granddaughter Adopted

DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS? (Please answer each one)

GENERAL: Fever, weight loss, weight gain, fatigue?	No Fever Weight loss Weight gain Fatigue
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat	No Allergies Sinus Problems Chronic Cough Dry Throat / Mouth Hard of Hearing
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease	No High BP Heart Surgery Vascular Disease
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD	No Asthma Bronchitis Emphysema COPD
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence	No Kidney stones Frequent urination Impotence Painful urination
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury	No Arthritis Joint pains Head or neck injury stiffness swelling cramps
SKIN: growths, rashes, acne	No Growths Rashes Acne
NEUROLOGICAL: Headaches, migraines, seizures	No Headaches Migraines Seizures numbness, paralysis
PSYCHIATRIC: Depression, Anxiety, Insomnia	No Depression Anxiety Insomnia
ENDOCRINE: Thyroid, Diabetes	No Diabetes Hypothyroid (underactive) Hyperthyroid (overactive)
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems	No Anemia Cholesterol Bleeding problems
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, M.S., Lupus, HIV	No Seasonal allergies Rheumatoid condition HIV / AIDS M.S. Lupus sneezing swelling redness itching hives
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux	No Diarrhea Constipation Ulcer Acid Reflux

STEP 6--Submit Data