New Patient Form

Vision Insurance

Insurance Information

Insurance Name:	None AETNA Anthem Blue Cross ANTHEM BLUE CROSS & BLUE SHIELD Block Vision, Inc. Blue Cross Blue Cross - VSP Blue Cross Blue Shield blue cross dis. blue cross eye med disc. blue cross of CALI. Blue cross of Calif. blue cross of california blue cross plus Blue cross, blueshield Blue Shield of California bluecross blueshield BRMS CHOICE PLUS CIGNA Cigna Open Access Plus compbenefits coopervision policy 767679 cuban warner DAVIS Davis Vision ebam ECCPA ecpa Eye Care Network EYE CARE PLAN OF AMERICA eye exam eye kraft Eye Med eye med blue cross eyekraft FHP FHP- secure horizon first health food employers joint trust f g b a GHPP GREAT WEST gva healthcomp healthy families, vsp HEATHLY FAMILIES labores trust fund max vision medi- Cal medi- Cal / medicare medi- Cal / V S P medi- Cal, medicare medi- Cal/ MEDICARE medi- Cal/MEDICARE medi-cal Medi-Cal/ VSP medical Medical Eye Services MEDICAL/MEDICARE Medicare Medicare, Medicare/ MEDI-CAL MERITAIN HEALTHCARE mesc none pacific atlantic Pacificare pacificare H m o PHCS private healthcar principal financial PRIVATE pru network Prudent Buyer Plan prudential reta plan S H 329397101 Safeguard Safeguard scan Secure Horizon Secure Horizon - plan 542 seiu spectera superior vision plan unicare united food and com united food commercial workers UNITED FOOD WORKER United Helthcare unocal VISION CARE DIRECT VISION CARE PLAN vision insur. plan of america Vision Service Plan (VSP) vsp exam plus/ eyemed vsp gift VSP, HEALTHY FAMILIES Vsp/ blue cross wasuga WAUSAU WRITERS GUILD
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

Insurance Information

Insurance Name:	None AETNA Anthem Blue Cross ANTHEM BLUE CROSS & BLUE SHIELD Block Vision, Inc. Blue Cross Blue Cross - VSP Blue Cross Blue Shield blue cross dis. blue cross eye med disc. blue cross of CALI. Blue cross of Calif. blue cross of california blue cross plus Blue cross, blueshield Blue Shield of California bluecross blueshield BRMS CHOICE PLUS CIGNA Cigna Open Access Plus compbenefits coopervision policy 767679 cuban warner DAVIS Davis Vision ebam ECCPA ecpa Eye Care Network EYE CARE PLAN OF AMERICA eye exam eye kraft Eye Med Eye Med 20% DISCOUNT eye med blue cross eyecare network 20% disc. eyekraft eyemed FHP FHP- secure horizon first health food employers joint trust f g b a GHPP Gigna GREAT WEST gva healthcomp healthy families, vsp HEATHLY FAMILIES labores trust fund max vision medi- Cal medi- Cal / medicare medi- Cal / medacare medi- Cal / V S P medi- Cal, medicare medi- Cal/ MEDICARE medi- Cal/MEDICARE medi-cal Medi-Cal/ VSP medical Medical Eye Services MEDICAL/MEDICARE medicare medicare / medical medicare / medical medicare, medicare/ medi-cal medicare/ MEDICAL MERITAIN HEALTHCARE mesc New Insurance New Insurance none pacific atlantic Pacificare pacificare H m o PHCS private healthcar principal financial PRIVATE pru network Prudent Buyer Plan prudental prudential reta plan S H 329397101 Safeguard Safeguard scan Secure Horizon Secure Horizon - plan 542 seiu spectera superior vision plan toba topa unicare united food and com united food commercial workers UNITED FOOD WORKER United Helthcare unocal VISION CARE DIRECT VISION CARE PLAN vision insur. plan of america Vision Service Pla558020103 Vision Service Plan Vision Service Plan (rand) Vision Service Plan / block VISION SERVICES PLAN vison service plan vsp exam plus/ eyemed vsp gift VSP, HEALTHY FAMILIES Vsp/ blue cross wasuga WAUSAU writers' guild WRITERS GUILD writers gulid
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:

Tertiary

Insurance Information

Insurance Name:	None AETNA Anthem Blue Cross ANTHEM BLUE CROSS & BLUE SHIELD Block Vision, Inc. Blue Cross Blue Cross - VSP Blue Cross Blue Shield blue cross dis. blue cross eye med disc. blue cross of CALI. Blue cross of Calif. blue cross of california blue cross plus Blue cross, blueshield Blue Shield of California bluecross blueshield BRMS CHOICE PLUS CIGNA Cigna Open Access Plus compbenefits coopervision policy 767679 cuban warner DAVIS Davis Vision ebam ECCPA ecpa Eye Care Network EYE CARE PLAN OF AMERICA eye exam eye kraft Eye Med Eye Med 20% DISCOUNT eye med blue cross eyecare network 20% disc. eyekraft eyemed FHP FHP- secure horizon first health food employers joint trust f g b a GHPP Gigna GREAT WEST gva healthcomp healthy families, vsp HEATHLY FAMILIES labores trust fund max vision medi- Cal medi- Cal / medicare medi- Cal / medacare medi- Cal / V S P medi- Cal, medicare medi- Cal/ MEDICARE medi- Cal/MEDICARE medi-cal Medi-Cal/ VSP medical Medical Eye Services MEDICAL/MEDICARE medicare medicare / medical medicare / medical medicare, medicare/ medi-cal medicare/ MEDICAL MERITAIN HEALTHCARE mesc New Insurance New Insurance none pacific atlantic Pacificare pacificare H m o PHCS private healthcar principal financial PRIVATE pru network Prudent Buyer Plan prudental prudential reta plan S H 329397101 Safeguard Safeguard scan Secure Horizon Secure Horizon - plan 542 seiu spectera superior vision plan toba topa unicare united food and com united food commercial workers UNITED FOOD WORKER United Helthcare unocal VISION CARE DIRECT VISION CARE PLAN vision insur. plan of america Vision Service Pla558020103 Vision Service Plan Vision Service Plan (rand) Vision Service Plan / block VISION SERVICES PLAN vison service plan vsp exam plus/ eyemed vsp gift VSP, HEALTHY FAMILIES Vsp/ blue cross wasuga WAUSAU writers' guild WRITERS GUILD writers gulid
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

EXAM TYPE

Established Patient Exam New Patient Exam Emergency Office Visit Contact lens fitting Glaucoma Exam Recheck purchased glasses

HOBBIES

N/A Sports Fishing Golf Music Crafts Sports Glass Blowing

What problems would you like to address at your eye exam today? (Ex: blurred vision, eye pain, out of contacts, etc)

Do you smoke or drink? How many times/week?

Eye History: Previous Injuries? Infections? Contact lens problems? Etc.

Please list any eye drops or eye medications you are taking.

Please list any other medications you are taking.

Allergies to Medications

OTHER ALLERGIES FAMILY HEALTH HISTORY (Diabetes? Hypertension? Stroke? Cancer? Etc. Please indicate who)

FAMILY EYE HISTORY (Glaucoma? Blindness? Cataract? Etc. Please indicate who)

How is your general health?:

Good Fair Poor Excellent

Ears, Nose, Throat:

none dry mouth cough ear ache hard of hearing stuffy nose

Cardiovascular:

none HTN Cholestrol Heart desease Stroke racing pulse

Respiratory:

none Asthma short of breath congestion wheezing

Genital, Kidney, Bladder:

none frequent urination impotence painful urination yellow jaundice Kidney failure Kidney disease

Muscles, Bones, Joints:

none arthritis cramps joint pain stiffness swelling

Skin:

none Eczema Acne rash growths Psoriasis

Neurological:

None headache numbness, paralysis seizures Fibromyalgia

Psychiatric:

None anxiety depression insomnia Bi-polar Mental disorders

Endocrine:

None NIDDM (type 2) IDDN (type 1) Hyperthyroid Hypothyroid Pit. Adenoma

Blood/Lymph:

none anemia bleeding cholestrolemia

Allergic/Immunologic

none hives itching lupus redness sneezing swelling HIV Hepatitis C Autoimmune disorders HIV Hepetitis C

Almost finished! The last few questions are only used for statistical analysis during Electronic Medical Records attestation.

Race

White Asian Hispanic Black or African American American Indian or Alaskan Native Hawaiian or Pacific Islander Declined

ethnicity

Hispanic or Latino Non Hispanic or Latino Declined

preferred language

English Spanish Declined

smoking status

Never Current every day smoker Current some day smoker Former smoker Smoker, current status not known Unknown if ever smoked

If you are a smoker, has a healthcare provider discussed quitting?

Yes No

Name of primary care doctor

Have you received a flu shot this year?

Do you have Hypertension?

Yes No

Submit Data

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