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:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN (last 4)		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

Is the Billing Address Different?

Billing Information

Address Same As Above

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:

Vision 1

Insurance Information

Insurance Name:	None A&I AARP ADDED CHOICE/KAISER ADVANTRA Adventist risk management AETNA INSURANCE AETNA MEDICARE PPO ALASKA CARE ALL CARE/ MID ROGUE AMERIBEN AMERICAN REPUBLIC INSURANCE CO AMERITAS AO/3M SAFETY APWU HEALTH PLAN ASSOCIATED ADMINISTRATORS ASSURANT HEALTH ATRIO HEALTH PLANS BANKERS LIFE & CASUALTY BCBS-TEAMSTERS BENEFIT & RISK MANAGEMENT SRVCS BENESIGHT BEST LIFE-DO NOT BILL BIOMASS ONE BOC GASES/LINDE BOISE CASCADE WORKERS COMP BOISE SAFETY GLASSES AND DISPENSING BOULDER ADMINISTRATIVE SERVICES CARE OREGON CARE OREGON MEDICARE ADVANTAGE CARE SOURCE CBSA CHAMPVA CIGNA HEALTHCARE CIGNA/GREATWEST HEALTHCARE CITY OF STAMFORD CLAIMS & BENEFIT MANAGEMENT CLEAR ONE COASTAL TPA COMBINED INSURANCE COVENTRY HEALTH CARE CRAWFORD & CO-WORK COMP KODAK CSI CYPRESS BENEFITS DEPARTMENT OF VETERANS AFFAIRS EBMS EMPIRE PACIFIC RISK MANAGEMENT EMPLOYEE BENEFIT MANAGEMENT CORP EMPLOYERS HEALTH ALLIANCE EQUITABLE LIFE & CASUALTY ESIS-WORK COMP LES SCHWAB EYEMED FAMILY CARE-DO NOT BILL FAMILY LIFE FARMERS INSURANCE FIRST CHOICE HEALTH NETWORK FIRST HEALTH FISERVE HEALTH GAURDIAN GE LIFE & ANNUITY GEHA GLOBE LIFE GOLD COAST JOINT BENEFITS TRUST HEALTH COMP HEALTH FUTURE HEALTH NET HEALTH NET MEDICARE ADVANTAGE PPO HEALTH REPUBLIC HEALTHCARE MANAGEMENT ADMIN. HUMANA IBMS ILWU-PMA COASTWISE CLAIMS IMG IMS INSURANCE MANAGEMENT SERVICES JACKSON CARE CONNECT JACKSON COUNTY HEALTH DEPT JOINT LABOR MGMT LOCAL 555 KNIFE RIVER LES SCHWAB BENEFITS DEPT. LIBERTY MUTUAL LIBERTY NORTHWEST LIFE MAP LIFEWISE LINDE LINDE ELECTRONICS LINE CONSTRUCTION BENEFIT FUND LIONS SIGHT & HEARING LOCAL 701 MEDICAL LOOMIS BENEFITS WEST LOYAL AMERICAN INSURANCE LTM-DO NOT BILL MAIL HANDLERS BENEFIT PLAN MEDICARE MEDICARE-DMERC MEDICO MEGA LIFE & HEALTH-MEDICAL ONLY MERITAIN HEALTH (AETNA NETWORK) MET LIFE MODA HEALTH PLAN MUTUAL OF OMAHA MUTUAL OF OMAHA RURAL CARRIER PLAN MVP HEALTH CARE NESIKA HEALTH GROUP New Insurance New Insurance NORTHWEST BENEFIT ADMIN NTCA-ASHEVILLE SERVICE CENTER NW LAUNDRY & DRYCLEANERS TRUST ODS-OHP (OREGON HEALTH PLAN) OEA CHOICE TRUST OLYMPIC HEALTH MANAGEMENT OREGON EYE COMMITTEE OREGON HEALTH MANAGEMENT SERVICE OREGON HEALTH PLAN- DMAP PACIFIC CREST PACIFIC GAS AND PACIFIC SOURCE PACIFIC SOURCE/SELECT BENEFITS PACIFICARE PENNSYLVANIA LIFE PERSCARE PHCO PHILLIPS ADMINISTRATIVE SERVICE PHYSICIANS LIFE INSURANCE PIONEER LIFE PRIMARY HEALTH OF JOSEPHINE COUNTY- OHP PRINCIPAL LIFE PROVIDENCE HEALTH PLAN PROVIDENCE PREFERRED PROVIDENT AMERICAN LIFE & HEALTH PYRAMID LIFE PYRAMID OPTIONS PREMIER QUEST QVI RISK MANAGEMENT RAILROAD MEDICARE REGENCE BLUE CROSS BLUE SHEILD RGA HEALTHCARE MGMT RNA SAFECO SAIF CORP SAMBA SANFORD HEALTH PLAN SECURE HORIZONS SECURITY LIFE SELECT BENEFIT ADMINISTRATORS SENTINEL SECURITY SHASTA ADMINISTRATIVE SERVICE SOUTHWEST CARPENTERS STANDARD LIFE STATE FARM CLAIM STATE FARM HEALTH INS STATE MUTUAL INSURANCE STERLING OPTION 1 STERLING PREMIER STONEBRIDGE LIFE SUPERIOR VISION SYMETRA THE PLAN HANDLERS, INC. TRADE TRICARE FOR LIFE/ WPS TRILLIUM TRUSTEED PLANS UFCW BAY AREA HLTH & WELFARE TRUST UFCW LOCAL UNION UMR UNIFORM MEDICAL PLAN UNITED AMERICAN INSURANCE CO. UNITED COMMERCIAL TRAVELERS OF AMERICA UNITED HEALTHCARE UNITED HEALTHCARE/ TRICARE WEST UNITED TEACHER ASSOCIATES VISION USA VSP WASHINGTON NATIONAL INSURANCE WEBTPA WELLCARE WESTERN GROCERS EMPLOYEE BENEFITS TRUST WILLIAM C. EARHART CO. WOS/ESSILOR WPAS LOCAL 701 VISION ZENITH ADMINISTRATORS
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 (last 4) :
Employer/School:

Vision 2

Insurance Information

Insurance Name:	None A&I AARP ADDED CHOICE/KAISER ADVANTRA Adventist risk management AETNA INSURANCE AETNA MEDICARE PPO ALASKA CARE ALL CARE/ MID ROGUE AMERIBEN AMERICAN REPUBLIC INSURANCE CO AMERITAS AO/3M SAFETY APWU HEALTH PLAN ASSOCIATED ADMINISTRATORS ASSURANT HEALTH ATRIO HEALTH PLANS BANKERS LIFE & CASUALTY BCBS-TEAMSTERS BENEFIT & RISK MANAGEMENT SRVCS BENESIGHT BEST LIFE-DO NOT BILL BIOMASS ONE BOC GASES/LINDE BOISE CASCADE WORKERS COMP BOISE SAFETY GLASSES AND DISPENSING BOULDER ADMINISTRATIVE SERVICES CARE OREGON CARE OREGON MEDICARE ADVANTAGE CARE SOURCE CBSA CHAMPVA CIGNA HEALTHCARE CIGNA/GREATWEST HEALTHCARE CITY OF STAMFORD CLAIMS & BENEFIT MANAGEMENT CLEAR ONE COASTAL TPA COMBINED INSURANCE COVENTRY HEALTH CARE CRAWFORD & CO-WORK COMP KODAK CSI CYPRESS BENEFITS DEPARTMENT OF VETERANS AFFAIRS EBMS EMPIRE PACIFIC RISK MANAGEMENT EMPLOYEE BENEFIT MANAGEMENT CORP EMPLOYERS HEALTH ALLIANCE EQUITABLE LIFE & CASUALTY ESIS-WORK COMP LES SCHWAB EYEMED FAMILY CARE-DO NOT BILL FAMILY LIFE FARMERS INSURANCE FIRST CHOICE HEALTH NETWORK FIRST HEALTH FISERVE HEALTH GAURDIAN GE LIFE & ANNUITY GEHA GLOBE LIFE GOLD COAST JOINT BENEFITS TRUST HEALTH COMP HEALTH FUTURE HEALTH NET HEALTH NET MEDICARE ADVANTAGE PPO HEALTH REPUBLIC HEALTHCARE MANAGEMENT ADMIN. HUMANA IBMS ILWU-PMA COASTWISE CLAIMS IMG IMS INSURANCE MANAGEMENT SERVICES JACKSON CARE CONNECT JACKSON COUNTY HEALTH DEPT JOINT LABOR MGMT LOCAL 555 KNIFE RIVER LES SCHWAB BENEFITS DEPT. LIBERTY MUTUAL LIBERTY NORTHWEST LIFE MAP LIFEWISE LINDE LINDE ELECTRONICS LINE CONSTRUCTION BENEFIT FUND LIONS SIGHT & HEARING LOCAL 701 MEDICAL LOOMIS BENEFITS WEST LOYAL AMERICAN INSURANCE LTM-DO NOT BILL MAIL HANDLERS BENEFIT PLAN MEDICARE MEDICARE-DMERC MEDICO MEGA LIFE & HEALTH-MEDICAL ONLY MERITAIN HEALTH (AETNA NETWORK) MET LIFE MODA HEALTH PLAN MUTUAL OF OMAHA MUTUAL OF OMAHA RURAL CARRIER PLAN MVP HEALTH CARE NESIKA HEALTH GROUP New Insurance New Insurance NORTHWEST BENEFIT ADMIN NTCA-ASHEVILLE SERVICE CENTER NW LAUNDRY & DRYCLEANERS TRUST ODS-OHP (OREGON HEALTH PLAN) OEA CHOICE TRUST OLYMPIC HEALTH MANAGEMENT OREGON EYE COMMITTEE OREGON HEALTH MANAGEMENT SERVICE OREGON HEALTH PLAN- DMAP PACIFIC CREST PACIFIC GAS AND PACIFIC SOURCE PACIFIC SOURCE/SELECT BENEFITS PACIFICARE PENNSYLVANIA LIFE PERSCARE PHCO PHILLIPS ADMINISTRATIVE SERVICE PHYSICIANS LIFE INSURANCE PIONEER LIFE PRIMARY HEALTH OF JOSEPHINE COUNTY- OHP PRINCIPAL LIFE PROVIDENCE HEALTH PLAN PROVIDENCE PREFERRED PROVIDENT AMERICAN LIFE & HEALTH PYRAMID LIFE PYRAMID OPTIONS PREMIER QUEST QVI RISK MANAGEMENT RAILROAD MEDICARE REGENCE BLUE CROSS BLUE SHEILD RGA HEALTHCARE MGMT RNA SAFECO SAIF CORP SAMBA SANFORD HEALTH PLAN SECURE HORIZONS SECURITY LIFE SELECT BENEFIT ADMINISTRATORS SENTINEL SECURITY SHASTA ADMINISTRATIVE SERVICE SOUTHWEST CARPENTERS STANDARD LIFE STATE FARM CLAIM STATE FARM HEALTH INS STATE MUTUAL INSURANCE STERLING OPTION 1 STERLING PREMIER STONEBRIDGE LIFE SUPERIOR VISION SYMETRA THE PLAN HANDLERS, INC. TRADE TRICARE FOR LIFE/ WPS TRILLIUM TRUSTEED PLANS UFCW BAY AREA HLTH & WELFARE TRUST UFCW LOCAL UNION UMR UNIFORM MEDICAL PLAN UNITED AMERICAN INSURANCE CO. UNITED COMMERCIAL TRAVELERS OF AMERICA UNITED HEALTHCARE UNITED HEALTHCARE/ TRICARE WEST UNITED TEACHER ASSOCIATES VISION USA VSP WASHINGTON NATIONAL INSURANCE WEBTPA WELLCARE WESTERN GROCERS EMPLOYEE BENEFITS TRUST WILLIAM C. EARHART CO. WOS/ESSILOR WPAS LOCAL 701 VISION ZENITH ADMINISTRATORS
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 (last 4) :
Employer/School:

Medical 1

Insurance Information

Insurance Name:	None A&I AARP ADDED CHOICE/KAISER ADVANTRA Adventist risk management AETNA INSURANCE AETNA MEDICARE PPO ALASKA CARE ALL CARE/ MID ROGUE AMERIBEN AMERICAN REPUBLIC INSURANCE CO AMERITAS AO/3M SAFETY APWU HEALTH PLAN ASSOCIATED ADMINISTRATORS ASSURANT HEALTH ATRIO HEALTH PLANS BANKERS LIFE & CASUALTY BCBS-TEAMSTERS BENEFIT & RISK MANAGEMENT SRVCS BENESIGHT BEST LIFE-DO NOT BILL BIOMASS ONE BOC GASES/LINDE BOISE CASCADE WORKERS COMP BOISE SAFETY GLASSES AND DISPENSING BOULDER ADMINISTRATIVE SERVICES CARE OREGON CARE OREGON MEDICARE ADVANTAGE CARE SOURCE CBSA CHAMPVA CIGNA HEALTHCARE CIGNA/GREATWEST HEALTHCARE CITY OF STAMFORD CLAIMS & BENEFIT MANAGEMENT CLEAR ONE COASTAL TPA COMBINED INSURANCE COVENTRY HEALTH CARE CRAWFORD & CO-WORK COMP KODAK CSI CYPRESS BENEFITS DEPARTMENT OF VETERANS AFFAIRS EBMS EMPIRE PACIFIC RISK MANAGEMENT EMPLOYEE BENEFIT MANAGEMENT CORP EMPLOYERS HEALTH ALLIANCE EQUITABLE LIFE & CASUALTY ESIS-WORK COMP LES SCHWAB EYEMED FAMILY CARE-DO NOT BILL FAMILY LIFE FARMERS INSURANCE FIRST CHOICE HEALTH NETWORK FIRST HEALTH FISERVE HEALTH GAURDIAN GE LIFE & ANNUITY GEHA GLOBE LIFE GOLD COAST JOINT BENEFITS TRUST HEALTH COMP HEALTH FUTURE HEALTH NET HEALTH NET MEDICARE ADVANTAGE PPO HEALTH REPUBLIC HEALTHCARE MANAGEMENT ADMIN. HUMANA IBMS ILWU-PMA COASTWISE CLAIMS IMG IMS INSURANCE MANAGEMENT SERVICES JACKSON CARE CONNECT JACKSON COUNTY HEALTH DEPT JOINT LABOR MGMT LOCAL 555 KNIFE RIVER LES SCHWAB BENEFITS DEPT. LIBERTY MUTUAL LIBERTY NORTHWEST LIFE MAP LIFEWISE LINDE LINDE ELECTRONICS LINE CONSTRUCTION BENEFIT FUND LIONS SIGHT & HEARING LOCAL 701 MEDICAL LOOMIS BENEFITS WEST LOYAL AMERICAN INSURANCE LTM-DO NOT BILL MAIL HANDLERS BENEFIT PLAN MEDICARE MEDICARE-DMERC MEDICO MEGA LIFE & HEALTH-MEDICAL ONLY MERITAIN HEALTH (AETNA NETWORK) MET LIFE MODA HEALTH PLAN MUTUAL OF OMAHA MUTUAL OF OMAHA RURAL CARRIER PLAN MVP HEALTH CARE NESIKA HEALTH GROUP New Insurance New Insurance NORTHWEST BENEFIT ADMIN NTCA-ASHEVILLE SERVICE CENTER NW LAUNDRY & DRYCLEANERS TRUST ODS-OHP (OREGON HEALTH PLAN) OEA CHOICE TRUST OLYMPIC HEALTH MANAGEMENT OREGON EYE COMMITTEE OREGON HEALTH MANAGEMENT SERVICE OREGON HEALTH PLAN- DMAP PACIFIC CREST PACIFIC GAS AND PACIFIC SOURCE PACIFIC SOURCE/SELECT BENEFITS PACIFICARE PENNSYLVANIA LIFE PERSCARE PHCO PHILLIPS ADMINISTRATIVE SERVICE PHYSICIANS LIFE INSURANCE PIONEER LIFE PRIMARY HEALTH OF JOSEPHINE COUNTY- OHP PRINCIPAL LIFE PROVIDENCE HEALTH PLAN PROVIDENCE PREFERRED PROVIDENT AMERICAN LIFE & HEALTH PYRAMID LIFE PYRAMID OPTIONS PREMIER QUEST QVI RISK MANAGEMENT RAILROAD MEDICARE REGENCE BLUE CROSS BLUE SHEILD RGA HEALTHCARE MGMT RNA SAFECO SAIF CORP SAMBA SANFORD HEALTH PLAN SECURE HORIZONS SECURITY LIFE SELECT BENEFIT ADMINISTRATORS SENTINEL SECURITY SHASTA ADMINISTRATIVE SERVICE SOUTHWEST CARPENTERS STANDARD LIFE STATE FARM CLAIM STATE FARM HEALTH INS STATE MUTUAL INSURANCE STERLING OPTION 1 STERLING PREMIER STONEBRIDGE LIFE SUPERIOR VISION SYMETRA THE PLAN HANDLERS, INC. TRADE TRICARE FOR LIFE/ WPS TRILLIUM TRUSTEED PLANS UFCW BAY AREA HLTH & WELFARE TRUST UFCW LOCAL UNION UMR UNIFORM MEDICAL PLAN UNITED AMERICAN INSURANCE CO. UNITED COMMERCIAL TRAVELERS OF AMERICA UNITED HEALTHCARE UNITED HEALTHCARE/ TRICARE WEST UNITED TEACHER ASSOCIATES VISION USA VSP WASHINGTON NATIONAL INSURANCE WEBTPA WELLCARE WESTERN GROCERS EMPLOYEE BENEFITS TRUST WILLIAM C. EARHART CO. WOS/ESSILOR WPAS LOCAL 701 VISION ZENITH ADMINISTRATORS
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 (last 4) :
Employer/School:

Medical 2

Insurance Information

Insurance Name:	None A&I AARP ADDED CHOICE/KAISER ADVANTRA Adventist risk management AETNA INSURANCE AETNA MEDICARE PPO ALASKA CARE ALL CARE/ MID ROGUE AMERIBEN AMERICAN REPUBLIC INSURANCE CO AMERITAS AO/3M SAFETY APWU HEALTH PLAN ASSOCIATED ADMINISTRATORS ASSURANT HEALTH ATRIO HEALTH PLANS BANKERS LIFE & CASUALTY BCBS-TEAMSTERS BENEFIT & RISK MANAGEMENT SRVCS BENESIGHT BEST LIFE-DO NOT BILL BIOMASS ONE BOC GASES/LINDE BOISE CASCADE WORKERS COMP BOISE SAFETY GLASSES AND DISPENSING BOULDER ADMINISTRATIVE SERVICES CARE OREGON CARE OREGON MEDICARE ADVANTAGE CARE SOURCE CBSA CHAMPVA CIGNA HEALTHCARE CIGNA/GREATWEST HEALTHCARE CITY OF STAMFORD CLAIMS & BENEFIT MANAGEMENT CLEAR ONE COASTAL TPA COMBINED INSURANCE COVENTRY HEALTH CARE CRAWFORD & CO-WORK COMP KODAK CSI CYPRESS BENEFITS DEPARTMENT OF VETERANS AFFAIRS EBMS EMPIRE PACIFIC RISK MANAGEMENT EMPLOYEE BENEFIT MANAGEMENT CORP EMPLOYERS HEALTH ALLIANCE EQUITABLE LIFE & CASUALTY ESIS-WORK COMP LES SCHWAB EYEMED FAMILY CARE-DO NOT BILL FAMILY LIFE FARMERS INSURANCE FIRST CHOICE HEALTH NETWORK FIRST HEALTH FISERVE HEALTH GAURDIAN GE LIFE & ANNUITY GEHA GLOBE LIFE GOLD COAST JOINT BENEFITS TRUST HEALTH COMP HEALTH FUTURE HEALTH NET HEALTH NET MEDICARE ADVANTAGE PPO HEALTH REPUBLIC HEALTHCARE MANAGEMENT ADMIN. HUMANA IBMS ILWU-PMA COASTWISE CLAIMS IMG IMS INSURANCE MANAGEMENT SERVICES JACKSON CARE CONNECT JACKSON COUNTY HEALTH DEPT JOINT LABOR MGMT LOCAL 555 KNIFE RIVER LES SCHWAB BENEFITS DEPT. LIBERTY MUTUAL LIBERTY NORTHWEST LIFE MAP LIFEWISE LINDE LINDE ELECTRONICS LINE CONSTRUCTION BENEFIT FUND LIONS SIGHT & HEARING LOCAL 701 MEDICAL LOOMIS BENEFITS WEST LOYAL AMERICAN INSURANCE LTM-DO NOT BILL MAIL HANDLERS BENEFIT PLAN MEDICARE MEDICARE-DMERC MEDICO MEGA LIFE & HEALTH-MEDICAL ONLY MERITAIN HEALTH (AETNA NETWORK) MET LIFE MODA HEALTH PLAN MUTUAL OF OMAHA MUTUAL OF OMAHA RURAL CARRIER PLAN MVP HEALTH CARE NESIKA HEALTH GROUP New Insurance New Insurance NORTHWEST BENEFIT ADMIN NTCA-ASHEVILLE SERVICE CENTER NW LAUNDRY & DRYCLEANERS TRUST ODS-OHP (OREGON HEALTH PLAN) OEA CHOICE TRUST OLYMPIC HEALTH MANAGEMENT OREGON EYE COMMITTEE OREGON HEALTH MANAGEMENT SERVICE OREGON HEALTH PLAN- DMAP PACIFIC CREST PACIFIC GAS AND PACIFIC SOURCE PACIFIC SOURCE/SELECT BENEFITS PACIFICARE PENNSYLVANIA LIFE PERSCARE PHCO PHILLIPS ADMINISTRATIVE SERVICE PHYSICIANS LIFE INSURANCE PIONEER LIFE PRIMARY HEALTH OF JOSEPHINE COUNTY- OHP PRINCIPAL LIFE PROVIDENCE HEALTH PLAN PROVIDENCE PREFERRED PROVIDENT AMERICAN LIFE & HEALTH PYRAMID LIFE PYRAMID OPTIONS PREMIER QUEST QVI RISK MANAGEMENT RAILROAD MEDICARE REGENCE BLUE CROSS BLUE SHEILD RGA HEALTHCARE MGMT RNA SAFECO SAIF CORP SAMBA SANFORD HEALTH PLAN SECURE HORIZONS SECURITY LIFE SELECT BENEFIT ADMINISTRATORS SENTINEL SECURITY SHASTA ADMINISTRATIVE SERVICE SOUTHWEST CARPENTERS STANDARD LIFE STATE FARM CLAIM STATE FARM HEALTH INS STATE MUTUAL INSURANCE STERLING OPTION 1 STERLING PREMIER STONEBRIDGE LIFE SUPERIOR VISION SYMETRA THE PLAN HANDLERS, INC. TRADE TRICARE FOR LIFE/ WPS TRILLIUM TRUSTEED PLANS UFCW BAY AREA HLTH & WELFARE TRUST UFCW LOCAL UNION UMR UNIFORM MEDICAL PLAN UNITED AMERICAN INSURANCE CO. UNITED COMMERCIAL TRAVELERS OF AMERICA UNITED HEALTHCARE UNITED HEALTHCARE/ TRICARE WEST UNITED TEACHER ASSOCIATES VISION USA VSP WASHINGTON NATIONAL INSURANCE WEBTPA WELLCARE WESTERN GROCERS EMPLOYEE BENEFITS TRUST WILLIAM C. EARHART CO. WOS/ESSILOR WPAS LOCAL 701 VISION ZENITH ADMINISTRATORS
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 (last 4) :
Employer/School:

Medical History

Reason for appointment. Please list any eye-related concerns.

Please list your occupation/school and hobbies. Also list the names & ages of your immediate family members:


OCULAR HISTORY

Last Eye Exam:		Doctor:
Result:		Last Dilation:

Do you experience any of the following?

Vision issues: (blur, flashes/floaters, halos, vision loss, light sensitivity, double vision, lazy eye, eye turn, lose attention easily, trouble with 3D movies, motion sickness / car sickenss, poor reading comprehension, poor tracking / eye movements)
Comfort issues: (dry, burning, red, tired, eye pain/soreness, watery, itchy, gritty/sandy feeling)
Motor-related issues: (poor motor control, clumsy / stumble easily, trouble catching a ball)
Eye disease: (cataracts, glaucoma, styes, keratoconus, macular degeneration)
Eye injuries:
Eye surgeries:
Additional Info:
Please list all eyedrops you use (OTC and Rx):
How often used?:

____________________________________________________________________________________________________________________________________________________________
MEDICAL HISTORY / REVIEW OF SYSTEMS:

Do you have, or ever had, any CHRONIC problems in the following areas?

General symptoms (Fever, weight loss/gain, other general problems):
Ear, nose, throat problems (sinus, ear infection, chronic cough, dry mouth, etc.):
Cardiac/vascular problems (high blood pressure, heart pain, vascular disease, etc.):		Hypertension?
Respiratory problems (asthma, emphysema, use of CPAP machine, etc.):
Gastrointestinal problems (stomach ulcers, reflex, stomach aches):
Genital, kidney or bladder problems:
Muscle, bone or joint problems (strains, sprains, broken bones, arthritis):
Skin problems (acne, warts, rosacea, skin cancer):
Neurological problems (multiple sclerosis, migraines, seizures, etc.):
Psychiatric/social problems (anxiety, depression, bipolar, insomnia, etc.):
Endocrine problems (diabetes, thyroid disorder, pituitary tumor, etc.):
Blood/lymphatic problems (high cholesterol, anemia, etc.):
Allergic/immune problems (hay fever, Lupus, Sjogrens, etc.):
Head injury/trauma (please describe):
Autism/spectrum disorder (please describe):
ADD/ADHD (please describe):
Other medical conditions/notes:

Surgical/Additional History:

Physician's Name:		Clinic:		Last Visit Date:
Other Physician's Name (specialist):		Clinic:		Last Visit Date:

No current medications
No known drug allergies

List all medications and reason you are currently taking (including any OTC/vitamins):


List any medications you are allergic to:

Pregnant or nursing?	No Yes
If yes, due/birth date:

Height:	ft.	in.
Weight:	lbs.

SOCIAL HISTORY (confidential):

Race:	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Patient Declined to Specify
Ethnicity:	Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify
Preferred Language:	English Spanish French Patient Declined to Specify
Smoking Status:	Never smoker (<100 lifetime cigarettes or equivalent quantity of cigar or pipe smoke) 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) Current every day smoker Unknown if ever smoked
Alcohol Use:

____________________________________________________________________________________________________________________________________________________________
FAMILY HISTORY

	RELATIONSHIP TO PATIENT
Blindness:	Nobody Mother Father Grandparent Sibling Child Unknown
Glaucoma:	Nobody Mother Father Grandparent Sibling Child Unknown
Cataracts:	Nobody Mother Father Grandparent Sibling Child Unknown
Macular Degeneration:	Nobody Mother Father Grandparent Sibling Child Unknown
Strabismus (eye turn):	Nobody Mother Father Grandparent Sibling Child Unknown
Amblyopia (lazy eye):	Nobody Mother Father Grandparent Sibling Child Unknown
Retinal Detachment:	Nobody Mother Father Grandparent Sibling Child Unknown

	RELATIONSHIP TO PATIENT
Rheumatoid Arthritis:	Nobody Mother Father Grandparent Sibling Child Unknown
Cancer:	Nobody Mother Father Grandparent Sibling Child Unknown
Diabetes:	Nobody Mother Father Grandparent Sibling Child Unknown
High Blood Pressure:	Nobody Mother Father Grandparent Sibling Child Unknown
Stroke:	Nobody Mother Father Grandparent Sibling Child Unknown
Heart Disease:	Nobody Mother Father Grandparent Sibling Child Unknown
Other Disease:	Nobody Mother Father Grandparent Sibling Child Unknown

______________________________________________________________________________________________________________________________________________________
CHILD'S DEVELOPMENTAL HISTORY

Type of Delivery:	Natural C-section Forceps / vacuum Anesthesia	Birth Weight:
Length of Pregnancy:		Relationship to Child:	Biological Adopted Foster My Grandchild Other

Complications/Incidents during Pregnancy:

Performance (subjective):	Above average Average Below average	Spoken Vocab:	Excellent Good Slow to develop
Testing/Treatment/Therapy?	No Yes	Eval Type:
Doctor/Location:		Date(s):

Notes:

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