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		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
Primary Eye Doctor	No Doctor Assigned Dr. Earley, Michael Dr. Strohl, Robert	Misc/Guardian
Primary Care Doctor

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:

Medical Insurance

Insurance Information

Insurance Name:	None New Insurance AARP Health Care Options(UHC) Aetna US Healthcare Anthem Avalon Benefits Services Avesis Vision Plan BAC Care First CHAMPVA Cigna Compbenefits Coresource Coventry-Mail Handlers Benefit Plan EBMC EV Benefits Mgt. Inc. Eyemed Vision Care/FAA Golden Rule Insurance Company GWH-Cigna Harrington Benefit Services Horizon Blue Cross Blue Shield of New Jersey Humana Choice Care Interplan Health Group Iron Workers Local #172 Klais And Company, Inc. Medben Medical Mutual Of Ohio Medicare- CGS Administrators, LLC. Meritain Health NGS American, Inc NVA Ohio Health Choice PHCS- Attach Card To Claim Polaris Benefit Administrators Railroad Medicare Security Life Insurance Spectera Eyecare Networks Superior Vision Services Inc. Tricare UFCW Health & Welfare Plan United Health Care United Healthcare All Savers United Healthcare of River Valley United Medical Resources VA Health Administration Center Vision Benefits Of America Vision Care Plan VSP
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:

Vision Insurance

Insurance Information

Insurance Name:	None New Insurance AARP Health Care Options(UHC) Aetna US Healthcare Anthem Avalon Benefits Services Avesis Vision Plan BAC Care First CHAMPVA Cigna Compbenefits Coresource Coventry-Mail Handlers Benefit Plan EBMC EV Benefits Mgt. Inc. Eyemed Vision Care/FAA Golden Rule Insurance Company GWH-Cigna Harrington Benefit Services Horizon Blue Cross Blue Shield of New Jersey Humana Choice Care Interplan Health Group Iron Workers Local #172 Klais And Company, Inc. Medben Medical Mutual Of Ohio Medicare- CGS Administrators, LLC. Meritain Health NGS American, Inc NVA Ohio Health Choice PHCS- Attach Card To Claim Polaris Benefit Administrators Railroad Medicare Security Life Insurance Spectera Eyecare Networks Superior Vision Services Inc. Tricare UFCW Health & Welfare Plan United Health Care United Healthcare All Savers United Healthcare of River Valley United Medical Resources VA Health Administration Center Vision Benefits Of America Vision Care Plan VSP
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:

Medical History

PLEASE SELECT WHAT TYPE OF EXAM WE WILL PERFORM:


Routine exam Routine exam with contacts Blurred vision at distance Blurred vision at near Blurred vision at distance and near Diabetic Eye Exam Contact Lens Progress Check Floaters Eye Pain Hazy Vision Red Eye Headaches Concerned about Cataracts Concerned about Glaucoma Concerned about ARMD Dry Eyes Itchy Eyes Follow-up for medical condition Post Op visit
REASON FOR VISIT-DO YOU HAVE ANY CONCERNS WE SHOULD DISCUSS DURING YOUR VISIT?

DO YOU TAKE MEDICATIONS?
no yes
PLEASE LIST CURRENT MEDICATIONS INCLUDING OVER THE COUNTER

DO YOU HAVE ANY ALLERGIES TO MEDICATIONS?
no yes
LIST ANY ALLERGIES TO MEDICATIONS
PRIMARY CARE PHYSICIAN

__________________________________________________________________________________________________________________________________________________________________
ARE YOU CURRENTLY EXPERIENCING ANY OF THE FOLLOWING:

Blurred Vision
YES or NO
no yes

Headaches
YES or NO
no yes

Eyestrain/Fatigue
YES or NO
no yes

Double Vision
YES or NO
no yes

Glare
YES or NO
no yes

Flashes of Light
YES or NO
no yes

Floaters
YES or NO
no yes

Dry Eyes
YES or NO
no yes

Itchy Eyes
YES or NO
no yes

Watery Eyes
YES or NO
no yes

Redness
YES or NO
yes

HAVE YOU OR ANYONE FAMILY MEMBER BEEN DIAGNOSED WITH THE FOLLOWING?: Answer YES or NO and list the family member.
Amblyopia/Lazy eye
no yes
none Self Mother Father Grandparent Brother Sister Aunt Uncle Great Grandparent Cousin Adopted

Blindness
no yes

none Self Mother Father Grandparent Brother Sister Aunt Uncle Great Grandparent Cousin Adopted

Cataract
no yes

none Self Mother Father Grandparent Brother Sister Aunt Uncle Great Grandparent Cousin Adopted

Color Blindness
no yes

none Self Mother Father Grandparent Brother Sister Aunt Uncle Great Grandparent Cousin Adopted
Glaucoma
no yes

none Self Mother Father Grandparent Brother Sister Aunt Uncle Great Grandparent Cosuin Adopted

Macular Degeneration
no yes

none Self Mother Father Grandparent Brother Sister Aunt Uncle Great Grandparent Cousin Adopted
Retinal Detachment
no yes

none Self Mother Father Grandparent Brother Sister Aunt Uncle Great Grandparent Cousin Adopted
Strabismus (eye turns or crosses)
no yes
none Self Mother Father Grandparent Brother Sister Aunt Uncle Great Grandparent Cousin Adopted
HAVE YOU HAD ANY PREVIOUS EYE SURGERIES
no yes
SURGERY INFORMATION/INFORMATION- SUCH AS SURGEON OR LOCATION;WHEN,ETC

Medical History Page 2

REVIEW OF SYSTEMS:

DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?

Constitutional: Fever, weight loss, weight gain, fatigue, trauma, other
no yes
None Developmental Disability Weight loss Weight gain Fever Fatigue Trauma other

EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat
no yes
None Allergies Sinus Problems Chronic Cough Dry Throat / Mouth Hard of Hearing


CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease, Stroke
no yes
None Hypertension Surgery Vascular Disease High Cholestrol Stroke
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD

no yes
None Asthma Bronchitis Emphysema COPD
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence, STD?

no yes
None painful urination frequent urination impotence jaundice kidney stones incontinence bladder infection STD
MUSCLES, BONES, JOINTS: Athritis, Joint Pains, Osteoarthritis, Head or Neck Injury


no yes
None joint pain stiffness swelling cramps arthritis Fibromyalgia Muscular Dystrophy Osteoarthritis

SKIN: Eczema, Rosacia, Psoriasis, growths, rashes, acne
no yes
None pimples, warts growths rash roscea acne melanoma eczema psoriasis

NEUROLOGICAL: Headaches, migraines, seizures, epilepsy, MS
no yes
None numbness, paralysis headache seizures migraines head trauma MS epilespy

PSYCHIATRIC: Depression, Anxiety, Insomnia, Panic disorder
no yes
None anxiety depression insomnia schizophrenia Bipolar Alzheimer's panic disorder

ENDOCRINE: Thyroid, Diabetes, Hormone dysfunction

no yes
None hypothyroid hyperthoyroid Diabetes Type I Diabetes Type II hormonal dysfunction other

BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
no yes
None Hypercholesterolemia bleeding anemia leukemia

ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus
no yes
None Seasonal allergies sneezing swelling redness itching hives lupus HIV drug allergy

GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux, Crohn's
no yes
None Diarrhea Constipation Ulcer Acid Reflux Crohn's Colitis other

CURRENTLY PREGNANT OR NURSING?
no yes

ARE YOU CURRENTLY BEING TREATED FOR DIABETES?
no yes

Type of Diabetes
Type I Type II Gestational Impaired Glucose Tolerace Pre-diabetes
WE WILL BE ASKING FOR MORE DETAILED DIABETIC INFORMATION DURING YOUR EXAM. THIS INCLUDES YOUR NORMAL FINGER STICK READINGS AND YOUR LAST HBA1C BLOOD TEST PERFORMED BY YOUR DOCTOR.

PLEASE CHECK BELOW THAT YOU ACKNOWLEDGE SHARING YOUR PRIVATE HEALTH INFORMATION VIA THE INTERNET:
I have read and understand the HIPAA Privacy Policies for North Star Vision Center at Olentangy
I have read and understand the Patient Responsibility Disclosure Statement for North Star Vision Center at Olentangy IF YOU ARE SATISFIED WITH THE INFORMATION YOU HAVE ENTERED PLEASE CLICK THE SUBMIT DATA BUTTON BELOW TO SEND US YOUR INFORMATION.