Online Patient Form
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After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!
Patient Information
First
Last
MI
Birthday:
SSN:
*SSN is required for insurance purposes. If you are uncomfortable providing this information online, please contact our office @ 406 522 8888
Address:
Apt/Suite #:
City:
State:
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
Zip Code:
Cell Phone:
Home Phone:
Work Phone:
Email
Preferred Contact?:
Home Phone
Work Phone
Cell Phone
Text Message
Email
Sex:
Male
Female
Employer / School
Occupation
Marital Status
Never Married
Married
Divorced
Widowed
Legally Separated
Race:
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Other Race
Rather Not Specify
Other
Spouse Name:
Contact Info:
Insurance Information
Insurance Name:
None
3rd Party Claims
Accident Insurance
Aetna
Aflac
All Savers/United Healthcare
Allegiance
Allied Benefit Systems
Always Care Benefits
AmeriBen
American Continental Insurance
Ameritas Life
Assurant
Assurant Health ASA
Assured Life Association
Attorney Claims
Auto Claims
Aventist Risk Management
Avesis Group (We do not participate)
Bankers Life
Banner Health Network
BCBS Medicare Adv
BCBS MT (Medical)
BCBS MT (V Group - MUS Only)
BCBS MT (V Group - Non-MUS)
BCBS MT Blue Chip (Healthy Montana Kids)
BCBS MT HELP Program
Best Life & Health Insurance Company
Boulder Administration Services
CDS Group Health
Cigna
Colonial Penn Life Insurance
Colony Brands
Coventry Health Care
Dept of VA - CHAMPUS
Design Benefits Admin/4 Your Choice
EBMS
Epic Life Insurance
Equitable Life & Casualty
Evolve (formerly Opticare Plus Vision)
Eyeconic
Eyemed
Eyemed Discount Plan
First Choice Health (Must get benefits phone# from card)
First Health/Coventry
Guardian Life (Vision Provider is Davis Vision or VSP)
Hartford
Health Partners Claims
Health Plans Inc
HealthScope Benefits Inc (Aetna/Aventist)
Humana
Humana Vision
Imerys Talc (Private Pay)
IMG
Kaiser Southern California
Life Insurance
Life Wise Health Plan of Oregon
Medica
Medicaid MT (Healthy Montana Kids PLUS)
Medicare
Medicare (Railroad Retirement Board)
Medico
Meritain Health/North American Administrators
MES Vision
Montana State Fund
Montana Teamsters (Vision)
MT Health Co-Op
Mutual of Omaha
N/A
Nothwestern Mutual
ODS Health Plan (We do not participate)
Pacific Source
PEHP (Public Employees Health Program)
Preferred One Health Insurance
Primary PhysicianCare Inc
Principal Life Insurance Company
Providence Health Plan of Oregon
Regional Care Inc
Select Health (Formerly IHC - HS)
Starmark Claims
State Farm - Arizona
Sterling Insurance Operations
Stratose
Superior Vision
Three Rivers Provider Network
TLC - Lasik & PRK Pre/Post Op
TriCare West Region Claims
UMR Claims
United Healthcare
United Healthcare Oxford
US Department of Labor
US Family Health Plan
VA (Summit Optical)
Veterans Choice Program VACCA (Office Fax records/w Auth)
VSP - Access Plan
VSP - Advantage Plan
VSP - Choice
VSP - Exam Plus
VSP - Signature
VSP - Vision Savings Pass
Western Growers Assurance Trust
Work Comp Claims
Zurich North America (Work Comp Only)
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:
Referral
Who may we thank for referring you to our office? Name of friend or relative:
How did you choose our office if not from a friend or relative?:
Doctor Referral:
Insurance List
Web Page:
Saw Sign/Building
Other:
Medical History
Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!
Please tell us why you're here today:
Previous Eye Doctor:
Date of Last Exam:
Primary Vision Correction:
None
Prescription Glasses
Prescription Reading Glasses
Soft Contacts
Non-Prescription Reading Glasses
Other
Do you: Have back up glasses?
No
Yes
Other
Want new glasses?
Yes
No
Other
Contact Lens Wearers only
Type of contacts worn in the past:
None
Disposable
Conventional
Colored
RGP
PMMA
Cobalt Study Lens
Soft
Other
Cleaner:
None
PureMoist
Optifree
Clear Care
Boston
Renu
Biotrue
Aquify
Other
Disposal:
daily
2 weeks
monthly
weekly
yearly
Other
Wear Time:
>2 hours today
All day
Occ. Overnight
Extended
8 hours
10 hours
12 hours
Overnight
Other
Days per week worn:
Hours per day worn:
Eye History
Do you currently have any of these symptoms?:
None
Itching
Burning, Stinging
Red
Floaters
Flashes Of Light
Eye Injuries
Eye Surgery
Amblyopia
Strabismus
Cataracts
Glaucoma
Retinal Disorders
Other
Do you take any of these eye medications?:
None
Cromolyn NA 4%
Visine
Patanol
Xalatan
Travatan
rewetting drops
Elestat
Vigamox
Alphagan
Refresh
Theratears
Genteal
Pred Forte
Lotemax
Alrex
Systane
Blink
Other
Family Eye History
Macular Degen:
No
Parents
Siblings
Grandparent
Other
Glaucoma:
No
Parents
Sibling
Grandparent
Other
Retinal Detach:
No
Parents
Siblings
Grandparent
Other
Cataracts:
No
Parents
Siblings
Grandparent
Other
Lazy/Crossed Eye:
No
Parents
Siblings
Grandparent
Other
Medications:
No Meds Used
Over The Counter Medications:
Vitamins:
Drug Allergies:
No Known Drug Allergies
Please describe any injuries or surgeries you have had:
Primary Care Physician:
Last Visit:
1 week
1 month
3 months
6 months
1 year
2 years
greater than 3 years
Other
Reason:
Check up
Annual
Specific
Other
Pregnant Or Nursing:
No
Yes
Unsure
Other
Recent Tetanus Shot:
Yes
No
Other
Family Medical History
Please select any conditions that apply to your family:
None
Adopted
Diabetes
HBP
Cancer
Cardiovascular Disease
Athritis
Kidney Disease
Lupus
Thyroid
Other
Review of Systems
General:
None
Fatigue
Fever
Loss of Appetite
Weight Gain
Weight Loss
Developmental Disorders
Other
Ear/Nose/Throat:
None
Neck Problems
Sinus Problems
Sore Throat (Recent)
Headache
Morning Headaches
Migraine Headache
Cluster Headache
Hearing Loss
Tinnitus
Congestion
Dry throat / mouth
Sleep Apnea
Other
Skin:
None
Acne
Lupus
Dermatitis
Eczema
Psoriasis
Rosacea
Skin Cancer
Itching
Other
Cardiovascular:
None
Congestive Heart Disease
Cardivascular Disease
High Cholesterol
Hypertension
Arrhythmia
Heart Murmur
Heart Palpitation
Chest Pain
Arteriosclerosis
Coagulation Disorder
Mitral Valve Prolapse
Low Blood Pressure
Other
Respiratory:
None
Asthma
Cancer: lung
Sleep Apnea
Sarcoidosis
COPD
Emphysema
Pneumonia
Bronchitis
Shortness of breath
Wheezing
Other
Musculoskeletal:
None
Arthritis
Osteoporosis
Fibromyalgia
Osteoarthritis
Muscular Dystrophy
Lupus
Decreased range of motion
Muscle cramps
Pain/tenderness
Stiffness
Swelling
Weakness
Other
Psychiatric:
None
Attention Deficit Disorder
Anxiety
Brain Damage (trauma)
Panic Attacks
Alzheimers Disease
Bi-polar
Depression
Insomnia
Obsessive/Compulsive
Paranoia
Suicidal
Violence
Other
Gastrointestinal:
None
Acid Reflux
Crohn's disease
Gastric reflux (GERD)
IBS
Ulcer
Gall bladder problems
Jaundice
Hepatitis
Sarcoidosis
Cancer: colon
Cancer: Liver
Other
Endocrine:
None
Crohn's disease
Diabetes Type 1
Diabetes Type 2
Diabetes Suspect
Hypothyroid
Hyperthoyroid
Gout
Hormone Replacement Therapy
Other
Blood/Lymph:
None
Anemia
Hx of Significant Blood Loss
Hematologic Disorder
Sickle Cell Disorder
Breast Carcinoma
Lymph Node Disease
Temporal Arthritis
Cuts slow to clot
Easy bruising
Other
Neurological:
None
Multiple Sclerosis
Seizure Disorder
Parkinsons Disease
Brian Tumor
Bells Palsy
Dyslexia
Headache
Balance problems
Vertigo
Tremors
Changes in senses
Dementia
Memory problems
Muscle weakness
Numbness, paralysis
Personality changes
Speech problems
Other
Genitourinary:
None
Amenorrhea
Menopause
Impotence
Jaundice
Uterine Cancer
Prostate Cancer
Kidney Stones
Pregnant
Nursing
Syphilis
Prostate Problems
Bladder Infections
STD- herpetic
STD- chlamydia
Other
Immune:
None
Seasonal allergies
Environmental allergies
Food allergies
Drug allergies (please specify)
Sjogrens syndrome
AIDS
Herpes Simplex
HIV Simplex
Mononucleosis
Tuberculosis
Cytomegalovirus Infection
Herpes Zoster
Lyme Disease
Sarcoidosis
Syphilis
Hives
Itching
Mild allergy symptoms
Severe allergy symptoms
Swelling
Other
Social History
Hobbies:
None
Art
Baseball
Astronomy
Boating
Basketball
Cooking
Crafts
Dancing
Diving
Football
Fishing
Golf
Gardening
Horseback Riding
Hunting
Models
Needlepoint
Painting
Photography
Piano
Reading
Running
Roller Blading
Softball
Sewing
Skiing
Soccer
Swimming
Tennis
Video Games
Woodworking
Other
STD's:
None
Gonorrhea
Syphilis
Hepatitis
HIV
TB
Other
Smoking Status:
Never smoker (<100 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)
Current every day smoker
Unknown if ever smoked
Other
Type:
None
Cigarettes
Chewing Tobacco
Other
How Long:
Alcohol Use:
No
Yes
Occasionally
Socially
Other
Type:
None
Beer
Wine
Hard Liquor
Other
How Long:
Illegal Drug Use:
No
Yes
Other
Type:
How Long
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Unknown
Patient Declined to Specify
Other
Preferred Language:
English
French
German
Spanish
Other
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