Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev. 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 Doctor	No Doctor Assigned Dr. Foley, Lauren Dr. Fukuda, Kenneth	Misc/Guardian
Primary Care Doctor

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. 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:

Primary

Insurance Information

Insurance Name:	None Aetna Insurance Blue Cross Blue Shield Cigna Davis Vision EyeMed Healthnet Logistics Health, Inc. Medical Eye Services Nippon Life Benefits Other Private Pay Safeguard So Cal Drug Benefit Fund Spectera/Optum Superior Vision UFCW United Health Care 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:

Secondary

Insurance Information

Insurance Name:	None Aetna Insurance Blue Cross Blue Shield Cigna Davis Vision EyeMed Healthnet Logistics Health, Inc. Medical Eye Services Nippon Life Benefits Other Private Pay Safeguard So Cal Drug Benefit Fund Spectera/Optum Superior Vision UFCW United Health Care 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:

Tertiary

Insurance Information

Insurance Name:	None Aetna Insurance Blue Cross Blue Shield Cigna Davis Vision EyeMed Healthnet Logistics Health, Inc. Medical Eye Services Nippon Life Benefits Other Private Pay Safeguard So Cal Drug Benefit Fund Spectera/Optum Superior Vision UFCW United Health Care 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

Insurance Information

Insurance Name:	None Aetna Insurance Blue Cross Blue Shield Cigna Davis Vision EyeMed Healthnet Logistics Health, Inc. Medical Eye Services Nippon Life Benefits Other Private Pay Safeguard So Cal Drug Benefit Fund Spectera/Optum Superior Vision UFCW United Health Care 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

Occupation:	Grad Student Professor Teacher Researcher Other	Referred By:	YELP Friend Family Insurance Yellow Pages PCP Google Other Website Other	Name of Referral:
Primary Care Physician:	Other	Last Eye Doctor:	Doesn't Remember Never Kaiser Out of State Lenscrafters Other
Last Eye Examination:	1 year ago 2 years ago 3 years ago 4 years ago 5 years ago Never, first time Other	Last Physical Exam	1 year ago 2 years ago 3 years ago 5 years ago Other

Systemic Meds:	None Aciphex Allegra Allegra D Albuterol Alprazolam Ambien Amoxicillin Atenolol Augmentin Avandia Birth Control Cephalexin Chlor-Trimeton Claritin Clonazepam Coumadin Diovan Enalapril Flexeril Fluoxetine Fosamax Furosemide Hydrochlorothyzide (HCTZ) Inderal Insulin Lamisil Lexapro Librax Lipitor Lisinopril Lorazepam Metformin Muscle Relax Metoprolol Minipress Nexium Norvasc Paroxetine Pamelor Plaquenil Plavix Potassium Chloride Prednisone Premarin Prevacid Protonix Reglan Relafen Sinequan SLO-BID Seldane Seldane-D Singulair Synthroid Thyroxine Toprol Verapamil Wellbutrin XL Zantac Zetia Zithromax Zocor Zoloft Zyrtec None Diazepam Fluconazole Altace Celebrex Viagra Doxycycline Lovastatin Allopurinol Clonidine Actos Pravachol Isosorbide Cozaar Glyburide Glucotrol Glipizide Tricor Coreg Lantus Mobic Flomax Crestor Ortho Tri-Cyclen Lo Temazepam Spironolactone Xalatan Topomax Combivent Gemfibrozil Avapro Amaryl Trinessa Imitrex Acyclovir Propanolol Zyprexa Lamictal Aricept Depakote Buspirone Cialis Methotrexate Terazosin Avalide Quinine Humalog Lanoxin Paxil CR Digoxin Levothroid Nortriptyline Phenytoin Phentermine Biaxin Lunesta Prempro Spiriva Flovent Captopril Inderal LA Vigamox Hydroxychloroquine Baclofen Hydrocortisone Proscar Tobradex Other
Allergies:	NKDA Environmental Seasonal PCN Sulfa Drugs Codeine Other	Eye Meds:	None alphagan P Art Tears Lumigan Cosopt Econopred Plus Patanol Systane Tobradex Timolol 0.5 Travatan Viroptic Visine Xalatan Zymar Other

Medical History: Has Arthritis, Asthma, Diabetes, HBP, Heart, Infl. Bowel Dz, Seizures, Thyroid, Smoke, Pregnant, Nursing, HIV+

Major Surgery or Illness

History of Eye Injury		History of Eye Surgery	None Lasik PRK Other	History of Eye Disease	None Eye Turn Lazy Eye ARMD Glaucoma Diabetic Retinopathy Retinal Detachment Corneal Dystophy Other
Family Med History (DM, HTN, Cancer, Thyroid):		Family Eye History (Glaucoma, Cataracts, ARMD, RD):

Alcohol?

No Yes Socially Rarely Occassionally Other

Smoke?

No Yes Other

Dryness?

Symptoms

Headaches?

No Everyday Few times/week Once/week Monthly Other

Review Of Systems

GENERAL: Fever, weight loss, weight gain, fatigue?	None Negative Other
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat	None Allergies Sinus Problems Chronic Cough Dry Throat / Mouth Hard of Hearing Other
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease	None Vascular Disease Heart Surgery Hypertension Cholesterol Other
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD	None Asthma Bronchitis Emphysema COPD Other
GENITAL, KIDNEY, BLADDER: K. Stones, Freq Urination, Impotence	None Painful Urination Frequent Urination Impotence Jaundice Other
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury	None Join Pain Stiffness Swelling Cramps Arthritis Osteoporosis Other
SKIN: growths, rashes, acne	None Pimples Warts Growths Rash Pigmentation Eczema Other
NEUROLOGICAL: Headaches, migraines, seizures	None Numbness Paralysis Headache Seizures Migraines Other
PSYCHIATRIC: Depression, Anxiety, Insomnia	None Anxiety Depression Insomnia ADD ADHD Other
ENDORCRINE: Thyroid, Diabetes	None Diabetes Hyperthyroid Hypothyroid Other
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems	None Bleeding Cholesteremia Anemia Other
ALLERGIC / IMMUN: Seasonal Allergies, RA, AIDS, Allergy Shots, Lupus	None Swelling Redness Itching Hives Lupus Other
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux	None Diarrhea Constipation Ulcer Acid Reflux Other

Submit Data