Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Address:
City:		State/ZipCode	AL AK AZ AR CA CO CT DE DC FL GA HI 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:	Text Message Cell Phone Email Work Phone Home Phone Other Phone
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
Misc/Guardian		Drivers License #

Is the Billing Address Different?

Billing Information

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Copy Address From Above
Address

City	State	ZipCode
	AL AK AZ AR CA CO CT DE DC FL GA HI 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 AETNA BCBS MEDICARE ADVANTAGE COMMUNITY VISION CARE EYEMED HUMANA M-BLUE CROSS BLUE SHIELD M-CIGNA M-UNITED HEALTH CARE MEDICARE MEDICARE - RAILROAD MEDICARE - SECONDARY MERITAIN HEALTH NO INSURANCE PRIVATE INSURANCE SECONDARY INS SUPERIOR VISION V-BLUE CROSS BLUE SHIELD V-CIGNA V-OTHER MISC INS V-UNITED HEALTH CARE VISION CARE PROVIDERS VISION SERVICE PLAN
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

Insurance Information

Insurance Name:	None AETNA BCBS MEDICARE ADVANTAGE COMMUNITY VISION CARE EYEMED HUMANA M-BLUE CROSS BLUE SHIELD M-CIGNA M-UNITED HEALTH CARE MEDICARE MEDICARE - RAILROAD MEDICARE - SECONDARY MERITAIN HEALTH NO INSURANCE PRIVATE INSURANCE SECONDARY INS SUPERIOR VISION V-BLUE CROSS BLUE SHIELD V-CIGNA V-OTHER MISC INS V-UNITED HEALTH CARE VISION CARE PROVIDERS VISION SERVICE PLAN
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:

Secondary

Insurance Information

Insurance Name:	None AETNA BCBS MEDICARE ADVANTAGE COMMUNITY VISION CARE EYEMED HUMANA M-BLUE CROSS BLUE SHIELD M-CIGNA M-UNITED HEALTH CARE MEDICARE MEDICARE - RAILROAD MEDICARE - SECONDARY MERITAIN HEALTH NO INSURANCE PRIVATE INSURANCE SECONDARY INS SUPERIOR VISION V-BLUE CROSS BLUE SHIELD V-CIGNA V-OTHER MISC INS V-UNITED HEALTH CARE VISION CARE PROVIDERS VISION SERVICE PLAN
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

To type in your own text, please select the 'type your own text' option from the drop down menu.

PATIENT MEDICAL Hx:

Injuries, Surgeries, Hospital:

Primary Care Physician

Doesn't Have One Doesn't Remember Type your own text

Tel

Fax

Allergies:

No known allergies Pollen Dust Mold Grass Food Seasonal Hay Fever Dogs Cats Other

Additional Meds

PATIENT OCULAR History:

Patient Uses:

None Bifocal Computer Rx Contacts Dist Gls OTC's Prog Bif Read Gls Rx Sunwear Type your own text

Contact Lens Type:

Disp 2 wk Disp Mo Disp Toric Disp Multi 1Day Disp 1Day Toric 1Day Multi RGP Monovision RGP Multifocal Type your own text

Family Medical and OCULAR History:

None Anemia Arthritis Asthma BLINDNESS Cancer CATARACTS Crohn's Diabetes GLAUCOMA Hay Fever Headache Heart Disease HTN Joint pain IBS Kidney disease LAZY EYE Lupus MACULAR DEGEN RETINAL DETACH Rosacea Sarcoid Seizure Stroke Thick glasses Thyroid Disease Other

Review Of Systems

EYES:	None Blur Burn Chronic Infections Discharge Mucus Distortion Double vision Dry Eye Strain Flashes Floaters Glare Gritty Itch Light sensitive Pain Red Spots Tearing Tired Vision Loss Other	NEUROLOGICAL:	None dizzy gait disturbance headache migraines numb seizures Vertigo Other
GENITOURINARY:	None fatigue fever night sweats weight gain weight loss Other	IMMUNOLOGIC:	None HIV Lupus RHEUMATOID ARTHRITIS Crohns Other
EAR, NOSE, THROAT:	None Allergies Chronic Cough Dry Throat / Mouth Hard of Hearing Hay fever Post Nasal Drip Runny Nose Sinus Problems None Other	CARDIO:	None High BP Chest pain Irregular heartbeat/palpitations Blood clot Heart Disease Disease Heart Other
GASTROINTESTINAL:	None constipation crohn's diarrhea hernia ulcers vomiting Other	PSYCHOLOGICAL:	None anxiety dementia Depression insomnia sadness Other
SKIN:	None acne eczema growths rash Other	BLOOD:	None anemia Blood Clots bruise/bleed easily cholesterol hypercholesterolemia Other
ENDOCRINE:	None Adrenal diabetes hyperthyroid hypothyroid thyroid Other	RESPIRATORY:	None Asthma Bronchitis Emphysema COPD Other
REPRO/URINE:	None bladder issues Genitalia impotence kidney problems prostate Sleep Apnea urination-frequent urination-painful Other	MUSCLE/SKELETAL	None Arthritis joint pain joint swelling muscle pain muscle weakness Rheumatoid arthritis Tendonitis Other

PREGNANT / NURSING

No Yes Unsure Type your own text

Race

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Patient Declined to Specify Type your own text

Ethnicity

Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Type your own text

Language

English Spanish Polish Arabic Bulgarian Cambodian Cantonese Central Khmer Chinese French German Haitian; Haitian Creole Hebrew Hindi Italian Japanese Korean Mandarin Portuguese Russian Somali Spanish; Castilian Swahili Thai Urdu Vietnamese declined Type your own text

Height
Ft.	in.	Weight

Occupation

Accountant Admin Assist Advertising Artist Athelete Banker Banquets Barber Bartender Business owner Cable Carpenter Computer field Construction Cosmotologist Counslor Day Care Dentist Doctor Driver Electrician Engineer Entepeneur Executive Executive assist Fireman Floral Food Graphic Designer Hair Stylist Homemaker Hospice Hospitality Insurance Interior Designer Investment Judge Laborer Lawyer Logistics Manager Mechanic Med Tech Musician Nanny Nurse Occ Therapist Para Legal Physician Assistant Phys Therapist Pilot Plumber Policeman Printer Professor Project mgr Psych Real Estate Realtor Reservationist Retail Retired Sales Salesman Self Employed Software design Student Teacher Teacher Assist Tollway Trader Waiter Waitress Warehouse Type your own text

Hobbies	Antiques Art Astronomy Baseball Basketball Biking Boating Bowling Ceramics Coin Collection Computers Cooking Crafts Crochet Crossword Puzzles Dancing Darts Diving Drawing Exercise Fishing Football Gardening Golf Hockey Horseback Riding Hunting LaCross Martial Arts Models Movies Music Needlepoint None Painting Photography Piano Pool Racket Ball Reading Roller Blading Running Sailing Sewing Shooting Skiing Skiing XX Soccer Softball Suduko Swimming Tennis TV Video Games Volleyball Woodworking Type your own text	Illegal Drugs	No Yes Type your own text
Tobacco	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 Type your own text	Alcohol	No Yes Occasionally Socially Type your own text