Online Patient Forms

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	Annulled Divorced Domestic partner Legally Separated Married Never Married Widowed	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Gustafson, Stephen Dr. Steed, David	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:

Vision

Insurance Information

Insurance Name:	None AARP UnitedHealth Care Aetna Aetna Choice Plan Aetna Individual Medicare Aetna Life Insurance Aetna Open Access Aetna Select Afflac Assurant Health/ASA BCBS Vision Claims Blue Cross Blue Shield Blue Cross Blue Shield of North Carolina BlueCross BlueShield of Illinois BlueCrossBlueShield of Texas Cigna EyeMed Vision Care Health Spring- Cigna Humana Kelsey Care Advantage Memorial Herman Health Insurance- Claims Dept Mutal of Omaha Insurance Co None- Spoke to Patient & they do not have Vison Ins Novitas Solutions Palmetto GBA, Railroad Principal Life Insurance Co. Railroad Medicare Part B Spectera Superior Vision Plan Supplement Insurance Not on File Texan Plus HMO TrailBlazerHealthEnterprises Tricare-Humana Military UHC Claims Department UHC Delta Retiress UMR United Health Care United of Omaha Life Ins. Co. UnitedHealthcare UnitedHealthCare Universal HMO of TX US Family Health Plan USSA Life Insurance Co. - Health Claims Vision Service Plan Vision Service Plan-DO NOT USE THIS
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

Insurance Information

Insurance Name:	None AARP UnitedHealth Care Aetna Aetna Choice Plan Aetna Individual Medicare Aetna Life Insurance Aetna Open Access Aetna Select Afflac Assurant Health/ASA BCBS Vision Claims Blue Cross Blue Shield Blue Cross Blue Shield of North Carolina BlueCross BlueShield of Illinois BlueCrossBlueShield of Texas Cigna EyeMed Vision Care Health Spring- Cigna Humana Kelsey Care Advantage Memorial Herman Health Insurance- Claims Dept Mutal of Omaha Insurance Co None- Spoke to Patient & they do not have Vison Ins Novitas Solutions Palmetto GBA, Railroad Principal Life Insurance Co. Railroad Medicare Part B Spectera Superior Vision Plan Supplement Insurance Not on File Texan Plus HMO TrailBlazerHealthEnterprises Tricare-Humana Military UHC Claims Department UHC Delta Retiress UMR United Health Care United of Omaha Life Ins. Co. UnitedHealthcare UnitedHealthCare Universal HMO of TX US Family Health Plan USSA Life Insurance Co. - Health Claims Vision Service Plan Vision Service Plan-DO NOT USE THIS
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:

Supplemental

Insurance Information

Insurance Name:	None AARP UnitedHealth Care Aetna Aetna Choice Plan Aetna Individual Medicare Aetna Life Insurance Aetna Open Access Aetna Select Afflac Assurant Health/ASA BCBS Vision Claims Blue Cross Blue Shield Blue Cross Blue Shield of North Carolina BlueCross BlueShield of Illinois BlueCrossBlueShield of Texas Cigna EyeMed Vision Care Health Spring- Cigna Humana Kelsey Care Advantage Memorial Herman Health Insurance- Claims Dept Mutal of Omaha Insurance Co None- Spoke to Patient & they do not have Vison Ins Novitas Solutions Palmetto GBA, Railroad Principal Life Insurance Co. Railroad Medicare Part B Spectera Superior Vision Plan Supplement Insurance Not on File Texan Plus HMO TrailBlazerHealthEnterprises Tricare-Humana Military UHC Claims Department UHC Delta Retiress UMR United Health Care United of Omaha Life Ins. Co. UnitedHealthcare UnitedHealthCare Universal HMO of TX US Family Health Plan USSA Life Insurance Co. - Health Claims Vision Service Plan Vision Service Plan-DO NOT USE THIS
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:

Reason for Visit

Please choose from the menu choices or select "Other" to type in multiple choices and custom text. Thank you!

Reason For Visit:

REVIEW OF OCULAR SYSTEM: Injuries, Infections, Surgeries, Diseases

Eye Drops:

None Alphagan Alrex Blink Genteal Lotemax Pataday Pred Forte Refresh Restasis rewetting drops Systane Balance Systane Ultra Theratears Tobradex Travatan Vigamox Visine Xalatan Other

Last Eye Exam:

1 year Unsure 2 years 3 years Other

Family Ocular History

Glaucoma:	No Parents Sibling Grandparent Other	Cataracts:	No Parents Siblings Grandparent Other	Macular Degen:	No Parents Siblings Grandparent Other
Retinal Detach:	No Parents Siblings Grandparent Other	Crossed / Lazy:	No Parents Siblings Grandparent Other

Past Prescriptions

Primary Vision Correction:

None Contacts - Soft Glasses-Full Time Glasses-Readers Only RGPs Other

Back up specs?

Yes No Other

Type of CLs worn in past:

ACUVUE OASYS 8.4/14.0 ACUVUE OASYS 8.8/14.0 ACUVUE 2 8.3/14.0 ACUVUE 2 8.7/14.0 ACUVUE OASYS ASTIGMATISM 8.6/14.5 ACUVUE ADVANCE PLUS 8.3/14.0 ACUVUE ADVANCE PLUS 8.7/14.0 ACUVUE ADVANCE ASTIGMATISM 8.6/14.5 ACUVUE 1-DAY MOIST 8.5/14.2 ACUVUE 1-DAY MOIST 9.0/14.2 ACUVUE 2 COLOURS OPAQUE 8.3/14.0 ACUVUE 2 COLOURS OPAQUE 8.7/14.0 ACUVUE 2 COLOURS ENHANCERS 8.3/14.0 ACUVUE 2 COLOURS ENHANCERS 8.7/14.0 ACUVUE 1-DAY TRUEYE 8.5/14.2 ACUVUE OASYS FOR PRESBYOPIA 8.4/14.3 AIR OPTIX AQUA 8.6/14.2 AIR OPTIX NIGHT&DAY 8.4/13.8 AIR OPTIX NIGHT&DAY 8.6/13.8 AIR OPTIX FOR ASTIGMATISM 8.7/14.5 AIR OPTIX MULTIFOCAL 8.6/14.2 AVAIRA 8.4/14.2 AVAIRA 8.5/14.2 AVAIRA TORIC 8.5/14.5 BIOFINITY 8.6/14.0 BIOFINITY TORIC 8.7/14.5 BIOFINITY MULTIFOCAL 8.6/14.0 BIOMEDICS 55 8.6/14.2 BIOMEDICS 55 8.8/14.2 BIOMEDICS 55 8.9/14.2 BIOMEDICS TORIC 8.7/14.5 BIOMEDICS 55 EVOLUTION (ULTRAFLEX II ASPHERIC) 8.6/14.2 BIOMEDICS 55 EVOLUTION (ULTRAFLEX II ASPHERIC) 8.8/14.2 BIOMEDICS 55 EVOLUTION (ULTRAFLEX II ASPHERIC) 8.9/14.2 BIOMEDICS 55 PREMIER 8.6/14.2 BIOMEDICS 55 PREMIER 8.8/14.2 BIOMEDICS 55 PREMIER 8.9/14.2 BIOMEDICS XC 8.5/14.2 BIOMEDICS EP(PROCLEAR EP) 8.7/14.4 BIOMEDICS 38 8.6/14.0 FOCUS DAILIES 8.6/13.8 FOCUS DAILIES AQUACOMFORT PLUS 8.7/14.0 FOCUS DAILIES TORIC 8.6/14.2 FOCUS DAILIES PROGRESSIVES 8.6/13.8 FREQUENCY 55 8.4/14.2 FREQUENCY 55 8.7/14.2 FREQUENCY 55 9.0/14.2 FREQUENCY 55 ASPHERIC 8.4/14.4 FREQUENCY 55 ASPHERIC 8.7/14.4 FREQUENCY 55 MULTIFOCAL 8.7/14.4 FREQUENCY 55 TORIC 8.4/14.4 FREQUENCY 55 TORIC 8.7/14.4 FREQUENCY 55 TORIC XR 8.4/14.4 FREQUENCY 55 TORIC XR 8.7/14.4 FRESHLOOK COLORLBENDS 8.6/14.5 FRESHLOOK COLORS 8.6/14.5 FRESHLOOK COLORBLENDS TORIC 8.4/14.5 FRESHLOOK DIMENSIONS 8.6/14.5 FRESHLOOK HANDLING TINT 8.6/14.5 FRESHLOOK COLORBLENDS ONE-DAY 8.6/13.8 FRESHLOOK TORIC 8.4/14.5 PROCLEAR 8.2/14.2 PROCLEAR 8.6/14.2 PROCLEAR TORIC 8.4/14.4 PROCLEAR TORIC 8.8/14.4 PROCLEAR MULTIFOCAL 8.7/14.4 PROCLEAR TORIC XR 8.4/14.4 PROCLEAR TORIC XR 8.8/14.4 PUREVISION 8.3/14.0 PUREVISION 8.6/14.0 PROCLEAR 8.6/14.0 PUREVISION MULTIFOCAL 8.6/14.0 PUREVISION TORIC 8.7/14.0 SOFLENS 38 8.4/14.0 SOFLENS 38 8.7/14.0 SOFLENS 38 9.0/14.0 SOFLENS DAILY DISPOSABLES 8.6/14.2 SOFLENS MULTI-FOCAL 8.5/14.5 SOFLENS MULTI-FOCAL 8.8/14.5 SOFLENS TORIC 8.5/14.5 Other

Wear Time:

8 - 10 Hours All day Occ. Overnight Extended Other

Cleaner:

Optifree Biotrue Clear Care Renu Boston Aquify Other

Disposal:

daily weekly 2 weeks monthly yearly Other

Medical History

Please choose from the menu choices or select "Other" to type in multiple choices and custom text. Thank you!

Injuries, Surgeries, Hospitalization

Pregnant Or Nursing:

No Yes Unsure Other

Notes:

Primary Care Physcian:

None Doesn't Have One Doesn't Remember Other

Last Visit:

1 week 1 month 3 months 6 months 1 year 2 years Other

Reason For Visit:

Check up Annual Other

Current Medications:

Over the Counter:

Allergies to Medications:

FAMILY MEDICAL HISTORY: Diabetes, HBP, Heart Dz, Cancer, Athritis, Lupus, Kidney, Thyroid, Other

SOCIAL HISTORY

Occupation:

Self Employed Student Other

Hobbies:

Art Astronomy Baseball Basketball Boating Cooking Crafts Dancing Diving Fishing Football Gardening Golf Horseback Riding Hunting Models Needlepoint None Painting Photography Piano Reading Roller Blading Running Sewing Skiing Soccer Softball Swimming Tennis Video Games Woodworking Other

Smoking Status:	Never Smoker Former smoker Current every day smoker Current some day smoker Smoker, currernt status unknown Unknown if ever smoked Other	Type:	Cigaretts Chewing Tobacco Other	How Long:
Alcohol:	No Yes Occasionally Socially Other	Type:	Beer Wine Hard Liquor Other	How Long:
Illegal Drugs:	No Yes Other	Type:		How Long:

Review of Systems

Please choose from the menu choices or select "Other" to type in multiple choices and custom text. Thank you!

GENERAL: Fever, weight loss, weight gain, fatigue?	Negative Fever Weight loss Weight gain Fatigue Other
NEUROLOGICAL: HEADACHES, migraines, Multiple Sclerosis	Negative headache migraines Multiple Sclerosis numbness, paralysis seizures Other
CARDIOVASCULAR: HIGH BLOOD PRESSURE, Vascular Disease	Negative high blood pressure Vascular Disease Other
ENDOCRINE: DIABETES, THYROID	Negative diabetes Thyroid disease Other
PSYCHIATRIC: Depression, Anxiety, Insomnia	Negative depression anxiety insomnia Other
EAR, NOSE, THROAT: Sinusitis, Cough, Dry Mouth / Throat	Negative Sinusitis Chronic Cough Dry Throat / Mouth Hard of Hearing Other
ALLERGIC / IMMUNOLOGIC: SEASONAL ALLERGIES, Lupus, AIDS, Allergy Shots	Negative Seasonal allergies lupus sneezing swelling redness itching hives Other
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD	Negative Asthma Bronchitis Emphysema COPD Other
MUSCLES, BONES, JOINTS: Athritis, Joint Pains, Head or Neck Injury	Negative arthritis joint pain stiffness swelling cramps Other
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux	Negative Gastrointestinal Diarrhea Constipation Ulcer Acid Reflux Other
GENITAL, KIDNEY, BLADDER: Kidney disease, Frequent Urination	Negative Kidney disease painful urination frequent urination impotence yellow jaundice Other
BLOOD/LYMPH: HIGH CHOLESTEROL, Anemia, bleeding problems	Negative high cholesterol bleeding anemia Other
SKIN: Psoriasis, growths, rashes, acne	Negative Psoriasis pimples, warts growths rash Other

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