Online Patient Form
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Patient Information
Title
First
Last
MI
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Nickname
Mr.
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Home Phone:
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Preferred Contact Method:
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Email
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Domestic partner
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Employer / School Name
Misc/Guardian
Billing Information
Is The Billing Address the Same?
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
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:
Home Phone:
Work Phone:
Primary Insurance
Insurance Name:
None
New Insurance
AARP HEALTH INSURANCE
AETNA
AETNA STRATEGIC RESOURCE CO.
ALLIED BENEFIT SYSTEMS, INC.
BANKERS LIFE AND CASUALTY INSURANCE COMPANY
BLUECROSS BLUESHIELD OF TEXAS
BOON-CHAPMAN BENEFIT ADMINISTRATORS, INC
CIGNA
COLONIAL PENN LIFE INSURANCE COMPANY
COMPBENEFITS (VCP-HUMANA VISION)
COVENTRY HEALTH CARE
CSI
DAVIS VISION
ENTRUST
EYEMED VISION
EYETOPIA VISION CARE
FIRST HEALTH
FREEDOM LIFE INSURANCE COMPANY
GEHA
GROUP & PENSION ADMINISTRATORS, INC
GWH-CIGNA
HEALTH CHOICE
HEALTH FIRST TPA
HEALTHSMART
HEARTLAND NATIONAL LIFE INSURANCE COMPANY
HUMANA CHOICE CARE
LOYAL AMERICAN LIFE INSURANCE COMPANY
MAIL HANDLERS BENEFIT PLAN
MANHATTAN LIFE INSURANCE COMPANY
MEDICAL MUTUAL
MEDICARE
MEDICO
MES VISION
MUTUAL OF OMAHA
NATIONAL VISION SERVICES
NEW ERA LIFE INSURANCE COMPANY
NVA
OLD SURETY LIFE INSURANCE CO
PACIFICARE
PHCS (NOT: LIFESTYLE HP)
PHYSICIANS MUTAL
PLUMBERS LOCAL UNION
Premier Provider Network
PRINCIPAL LIFE INSRANCE COMPANY
PROTECTIVE VISION/ ACCESS VISION NETWORK
PROVIDENT AMERICAN LIFE AND HEALTH INSUR
REGENCE BCBS OF UTAH
RELIANT STANDARD
SAFEGUARD
SCOTT AND WHITE HEALTH PLAN
SELF PAY
SENTINEL SECURITY LIFE INSURANCE CO
SPECTERA
STARMARK
SUPERIOR VISION
TOWER LIFE INSURANCE CO.
TRICARE SOUTH REGION
UMR
UNITED AMERICAN INS CO
UNITED HEALTHCARE
UNIVERSAL HEALTH CARE
USAA
VISION BENEFITS OF AMERICA
VISION SERVICE PLAN
WELLCARE
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
Insurance Name:
None
New Insurance
AARP HEALTH INSURANCE
AETNA
AETNA STRATEGIC RESOURCE CO.
ALLIED BENEFIT SYSTEMS, INC.
BANKERS LIFE AND CASUALTY INSURANCE COMPANY
BLUECROSS BLUESHIELD OF TEXAS
BOON-CHAPMAN BENEFIT ADMINISTRATORS, INC
CIGNA
COLONIAL PENN LIFE INSURANCE COMPANY
COMPBENEFITS (VCP-HUMANA VISION)
COVENTRY HEALTH CARE
CSI
DAVIS VISION
ENTRUST
EYEMED VISION
EYETOPIA VISION CARE
FIRST HEALTH
FREEDOM LIFE INSURANCE COMPANY
GEHA
GROUP & PENSION ADMINISTRATORS, INC
GWH-CIGNA
HEALTH CHOICE
HEALTH FIRST TPA
HEALTHSMART
HEARTLAND NATIONAL LIFE INSURANCE COMPANY
HUMANA CHOICE CARE
LOYAL AMERICAN LIFE INSURANCE COMPANY
MAIL HANDLERS BENEFIT PLAN
MANHATTAN LIFE INSURANCE COMPANY
MEDICAL MUTUAL
MEDICARE
MEDICO
MES VISION
MUTUAL OF OMAHA
NATIONAL VISION SERVICES
NEW ERA LIFE INSURANCE COMPANY
NVA
OLD SURETY LIFE INSURANCE CO
PACIFICARE
PHCS (NOT: LIFESTYLE HP)
PHYSICIANS MUTAL
PLUMBERS LOCAL UNION
Premier Provider Network
PRINCIPAL LIFE INSRANCE COMPANY
PROTECTIVE VISION/ ACCESS VISION NETWORK
PROVIDENT AMERICAN LIFE AND HEALTH INSUR
REGENCE BCBS OF UTAH
RELIANT STANDARD
SAFEGUARD
SCOTT AND WHITE HEALTH PLAN
SELF PAY
SENTINEL SECURITY LIFE INSURANCE CO
SPECTERA
STARMARK
SUPERIOR VISION
TOWER LIFE INSURANCE CO.
TRICARE SOUTH REGION
UMR
UNITED AMERICAN INS CO
UNITED HEALTHCARE
UNIVERSAL HEALTH CARE
USAA
VISION BENEFITS OF AMERICA
VISION SERVICE PLAN
WELLCARE
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
Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!
Medical History: Arthritis, Asthma, Diabetes, HBP, Heart, Infl. Bowel Dz, Seizures, Thyroid
Good Health
ACNE ROSACEA
ANEMIA
Arthirits-Rheumatoid
ARTHRITIS
Arthritis-osteo
ASTHMA
ATTENTION DISORDER
AUTISM
BACTERIAL INFECTION
BELL'S PALSY
BLOOD/BLEEDING DISORDER
BRAIN INJURY
BRAIN TUMOR
BREAST CANCER
Cholesterol elevated
COLON CANCER
CONSTIPATION
CONTACT DERMATITIS
COPD
DEPRESSION
Diabetes (Insulin)
Diabetes (oral meds)
DRY MOUTH
EAR INFECTION
HBP
HEADACHE
HEARING PROBLEMS
Heart Condition
HEPATITIS A
HEPATITIS B
HEPATITIS C
HISTOPLASMOSIS
HIV POSITIVE
HORNER'S SYNDROME
KIDNEY DISEASE
KIDNEY STONES
LEARNING DISABILITY
LEUKEMIA
LUNG DISEASE
LUPUS
MEMORY LOSS
MIGRAINE
MULTIPLE SCLEROSIS
MUSCULAR DYSTROPHY
MYASTHENIA GRAVIS
Nursing
PHOTOSENSITIVITY
PREGNANCY PROBLEMS
PREGNANT NOW
PROSTATE DISORDER
SARCOIDOSIS
SEIZURES
SICKLE CELL
SJOGREN'S SYNDROME
STROKE
Thyroid Disease
TUBERCULOSIS
ULCER
Other
ACNE ROSACEA
ANEMIA
Arthirits-Rheumatoid
ARTHRITIS
Arthritis-osteo
ASTHMA
ATTENTION DISORDER
AUTISM
BACTERIAL INFECTION
BELL'S PALSY
BLOOD/BLEEDING DISORDER
BRAIN INJURY
BRAIN TUMOR
BREAST CANCER
Cholesterol elevated
COLON CANCER
CONSTIPATION
CONTACT DERMATITIS
COPD
DEPRESSION
Diabetes (Insulin)
Diabetes (oral meds)
DRY MOUTH
EAR INFECTION
Good health
HBP
HEADACHE
HEARING PROBLEMS
Heart Condition
HEPATITIS A
HEPATITIS B
HEPATITIS C
HISTOPLASMOSIS
HIV POSITIVE
HORNER'S SYNDROME
KIDNEY DISEASE
KIDNEY STONES
LEARNING DISABILITY
LEUKEMIA
LUNG DISEASE
LUPUS
MEMORY LOSS
MIGRAINE
MULTIPLE SCLEROSIS
MUSCULAR DYSTROPHY
MYASTHENIA GRAVIS
Nursing
PHOTOSENSITIVITY
PREGNANCY PROBLEMS
PREGNANT NOW
PROSTATE DISORDER
SARCOIDOSIS
SEIZURES
SICKLE CELL
SJOGREN'S SYNDROME
STROKE
Thyroid Disease
TUBERCULOSIS
ULCER
Other
ACNE ROSACEA
ANEMIA
Arthirits-Rheumatoid
ARTHRITIS
Arthritis-osteo
ASTHMA
ATTENTION DISORDER
AUTISM
BACTERIAL INFECTION
BELL'S PALSY
BLOOD/BLEEDING DISORDER
BRAIN INJURY
BRAIN TUMOR
BREAST CANCER
Cholesterol elevated
COLON CANCER
CONSTIPATION
CONTACT DERMATITIS
COPD
DEPRESSION
Diabetes (Insulin)
Diabetes (oral meds)
DRY MOUTH
EAR INFECTION
Good health
HBP
HEADACHE
HEARING PROBLEMS
Heart Condition
HEPATITIS A
HEPATITIS B
HEPATITIS C
HISTOPLASMOSIS
HIV POSITIVE
HORNER'S SYNDROME
KIDNEY DISEASE
KIDNEY STONES
LEARNING DISABILITY
LEUKEMIA
LUNG DISEASE
LUPUS
MEMORY LOSS
MIGRAINE
MULTIPLE SCLEROSIS
MUSCULAR DYSTROPHY
MYASTHENIA GRAVIS
Nursing
PHOTOSENSITIVITY
PREGNANCY PROBLEMS
PREGNANT NOW
PROSTATE DISORDER
SARCOIDOSIS
SEIZURES
SICKLE CELL
SJOGREN'S SYNDROME
STROKE
Thyroid Disease
TUBERCULOSIS
ULCER
Other
ACNE ROSACEA
ANEMIA
Arthirits-Rheumatoid
ARTHRITIS
Arthritis-osteo
ASTHMA
ATTENTION DISORDER
AUTISM
BACTERIAL INFECTION
BELL'S PALSY
BLOOD/BLEEDING DISORDER
BRAIN INJURY
BRAIN TUMOR
BREAST CANCER
Cholesterol elevated
COLON CANCER
CONSTIPATION
CONTACT DERMATITIS
COPD
DEPRESSION
Diabetes (Insulin)
Diabetes (oral meds)
DRY MOUTH
EAR INFECTION
Good health
HBP
HEADACHE
HEARING PROBLEMS
Heart Condition
HEPATITIS A
HEPATITIS B
HEPATITIS C
HISTOPLASMOSIS
HIV POSITIVE
HORNER'S SYNDROME
KIDNEY DISEASE
KIDNEY STONES
LEARNING DISABILITY
LEUKEMIA
LUNG DISEASE
LUPUS
MEMORY LOSS
MIGRAINE
MULTIPLE SCLEROSIS
MUSCULAR DYSTROPHY
MYASTHENIA GRAVIS
Nursing
PHOTOSENSITIVITY
PREGNANCY PROBLEMS
PREGNANT NOW
PROSTATE DISORDER
SARCOIDOSIS
SEIZURES
SICKLE CELL
SJOGREN'S SYNDROME
STROKE
Thyroid Disease
TUBERCULOSIS
ULCER
Other
ACNE ROSACEA
ANEMIA
Arthirits-Rheumatoid
ARTHRITIS
Arthritis-osteo
ASTHMA
ATTENTION DISORDER
AUTISM
BACTERIAL INFECTION
BELL'S PALSY
BLOOD/BLEEDING DISORDER
BRAIN INJURY
BRAIN TUMOR
BREAST CANCER
Cholesterol elevated
COLON CANCER
CONSTIPATION
CONTACT DERMATITIS
COPD
DEPRESSION
Diabetes (Insulin)
Diabetes (oral meds)
DRY MOUTH
EAR INFECTION
Good health
HBP
HEADACHE
HEARING PROBLEMS
Heart Condition
HEPATITIS A
HEPATITIS B
HEPATITIS C
HISTOPLASMOSIS
HIV POSITIVE
HORNER'S SYNDROME
KIDNEY DISEASE
KIDNEY STONES
LEARNING DISABILITY
LEUKEMIA
LUNG DISEASE
LUPUS
MEMORY LOSS
MIGRAINE
MULTIPLE SCLEROSIS
MUSCULAR DYSTROPHY
MYASTHENIA GRAVIS
Nursing
PHOTOSENSITIVITY
PREGNANCY PROBLEMS
PREGNANT NOW
PROSTATE DISORDER
SARCOIDOSIS
SEIZURES
SICKLE CELL
SJOGREN'S SYNDROME
STROKE
Thyroid Disease
TUBERCULOSIS
ULCER
Other
ACNE ROSACEA
ANEMIA
Arthirits-Rheumatoid
ARTHRITIS
Arthritis-osteo
ASTHMA
ATTENTION DISORDER
AUTISM
BACTERIAL INFECTION
BELL'S PALSY
BLOOD/BLEEDING DISORDER
BRAIN INJURY
BRAIN TUMOR
BREAST CANCER
Cholesterol elevated
COLON CANCER
CONSTIPATION
CONTACT DERMATITIS
COPD
DEPRESSION
Diabetes (Insulin)
Diabetes (oral meds)
DRY MOUTH
EAR INFECTION
Good health
HBP
HEADACHE
HEARING PROBLEMS
Heart Condition
HEPATITIS A
HEPATITIS B
HEPATITIS C
HISTOPLASMOSIS
HIV POSITIVE
HORNER'S SYNDROME
KIDNEY DISEASE
KIDNEY STONES
LEARNING DISABILITY
LEUKEMIA
LUNG DISEASE
LUPUS
MEMORY LOSS
MIGRAINE
MULTIPLE SCLEROSIS
MUSCULAR DYSTROPHY
MYASTHENIA GRAVIS
Nursing
PHOTOSENSITIVITY
PREGNANCY PROBLEMS
PREGNANT NOW
PROSTATE DISORDER
SARCOIDOSIS
SEIZURES
SICKLE CELL
SJOGREN'S SYNDROME
STROKE
Thyroid Disease
TUBERCULOSIS
ULCER
Other
Reason for Visit:
Secondary Reasons:
Medications:
None
Actos
Acyclovir
Adderall
Albuterol
Allegra
Altase
Amaryl
Amiodarone
Amoxycillin
Atenolol
Augmentin
Bactroban
Buspar
Captopril
Carbamazepine
Cefzil
Celebrex
Cipro
Clonidin
Coumadin
Cozar
Crestor
Depakote
Detrol
Diclofenac
Dilantin
Diovan
Effexor
Flomax
Flonase
Furosamide
Glucophage
Glyburide
HCTZ
Humulin
Hydrocortisone
Lasix
Levaquin
Lipitor
Lisinopril
Lortab
Metformin
Methlyprednisolone
MS Contin
Nasacort
Novalog
Oxycodone
Pepcid
Plaquenil
Plavix
Prednisone
Premarin
Prempro
Protonix
Proventil
Prozac
Ritalin
Singular
Synthroid
Tetracycline
Topamax
Valium
Wellbutrin
Xanax
Zantac
Zestril
Zoloft
Other
None
Actos
Acyclovir
Adderall
Albuterol
Allegra
Altase
Amaryl
Amiodarone
Amoxycillin
Atenolol
Augmentin
Bactroban
Buspar
Captopril
Carbamazepine
Cefzil
Celebrex
Cipro
Clonidin
Coumadin
Cozar
Crestor
Depakote
Detrol
Diclofenac
Dilantin
Diovan
Effexor
Flomax
Flonase
Furosamide
Glucophage
Glyburide
HCTZ
Humulin
Hydrocortisone
Lasix
Levaquin
Lipitor
Lisinopril
Lortab
Metformin
Methlyprednisolone
MS Contin
Nasacort
Novalog
Oxycodone
Pepcid
Plaquenil
Plavix
Prednisone
Premarin
Prempro
Protonix
Proventil
Prozac
Ritalin
Singular
Synthroid
Tetracycline
Topamax
Valium
Wellbutrin
Xanax
Zantac
Zestril
Zoloft
Other
None
Actos
Acyclovir
Adderall
Albuterol
Allegra
Altase
Amaryl
Amiodarone
Amoxycillin
Atenolol
Augmentin
Bactroban
Buspar
Captopril
Carbamazepine
Cefzil
Celebrex
Cipro
Clonidin
Coumadin
Cozar
Crestor
Depakote
Detrol
Diclofenac
Dilantin
Diovan
Effexor
Flomax
Flonase
Furosamide
Glucophage
Glyburide
HCTZ
Humulin
Hydrocortisone
Lasix
Levaquin
Lipitor
Lisinopril
Lortab
Metformin
Methlyprednisolone
MS Contin
Nasacort
Novalog
Oxycodone
Pepcid
Plaquenil
Plavix
Prednisone
Premarin
Prempro
Protonix
Proventil
Prozac
Ritalin
Singular
Synthroid
Tetracycline
Topamax
Valium
Wellbutrin
Xanax
Zantac
Zestril
Zoloft
Other
None
Actos
Acyclovir
Adderall
Albuterol
Allegra
Altase
Amaryl
Amiodarone
Amoxycillin
Atenolol
Augmentin
Bactroban
Buspar
Captopril
Carbamazepine
Cefzil
Celebrex
Cipro
Clonidin
Coumadin
Cozar
Crestor
Depakote
Detrol
Diclofenac
Dilantin
Diovan
Effexor
Flomax
Flonase
Furosamide
Glucophage
Glyburide
HCTZ
Humulin
Hydrocortisone
Lasix
Levaquin
Lipitor
Lisinopril
Lortab
Metformin
Methlyprednisolone
MS Contin
Nasacort
Novalog
Oxycodone
Pepcid
Plaquenil
Plavix
Prednisone
Premarin
Prempro
Protonix
Proventil
Prozac
Ritalin
Singular
Synthroid
Tetracycline
Topamax
Valium
Wellbutrin
Xanax
Zantac
Zestril
Zoloft
Other
None
Actos
Acyclovir
Adderall
Albuterol
Allegra
Altase
Amaryl
Amiodarone
Amoxycillin
Atenolol
Augmentin
Bactroban
Buspar
Captopril
Carbamazepine
Cefzil
Celebrex
Cipro
Clonidin
Coumadin
Cozar
Crestor
Depakote
Detrol
Diclofenac
Dilantin
Diovan
Effexor
Flomax
Flonase
Furosamide
Glucophage
Glyburide
HCTZ
Humulin
Hydrocortisone
Lasix
Levaquin
Lipitor
Lisinopril
Lortab
Metformin
Methlyprednisolone
MS Contin
Nasacort
Novalog
Oxycodone
Pepcid
Plaquenil
Plavix
Prednisone
Premarin
Prempro
Protonix
Proventil
Prozac
Ritalin
Singular
Synthroid
Tetracycline
Topamax
Valium
Wellbutrin
Xanax
Zantac
Zestril
Zoloft
Other
None
Actos
Acyclovir
Adderall
Albuterol
Allegra
Altase
Amaryl
Amiodarone
Amoxycillin
Atenolol
Augmentin
Bactroban
Buspar
Captopril
Carbamazepine
Cefzil
Celebrex
Cipro
Clonidin
Coumadin
Cozar
Crestor
Depakote
Detrol
Diclofenac
Dilantin
Diovan
Effexor
Flomax
Flonase
Furosamide
Glucophage
Glyburide
HCTZ
Humulin
Hydrocortisone
Lasix
Levaquin
Lipitor
Lisinopril
Lortab
Metformin
Methlyprednisolone
MS Contin
Nasacort
Novalog
Oxycodone
Pepcid
Plaquenil
Plavix
Prednisone
Premarin
Prempro
Protonix
Proventil
Prozac
Ritalin
Singular
Synthroid
Tetracycline
Topamax
Valium
Wellbutrin
Xanax
Zantac
Zestril
Zoloft
Other
None
Actos
Acyclovir
Adderall
Albuterol
Allegra
Altase
Amaryl
Amiodarone
Amoxycillin
Atenolol
Augmentin
Bactroban
Buspar
Captopril
Carbamazepine
Cefzil
Celebrex
Cipro
Clonidin
Coumadin
Cozar
Crestor
Depakote
Detrol
Diclofenac
Dilantin
Diovan
Effexor
Flomax
Flonase
Furosamide
Glucophage
Glyburide
HCTZ
Humulin
Hydrocortisone
Lasix
Levaquin
Lipitor
Lisinopril
Lortab
Metformin
Methlyprednisolone
MS Contin
Nasacort
Novalog
Oxycodone
Pepcid
Plaquenil
Plavix
Prednisone
Premarin
Prempro
Protonix
Proventil
Prozac
Ritalin
Singular
Synthroid
Tetracycline
Topamax
Valium
Wellbutrin
Xanax
Zantac
Zestril
Zoloft
Other
None
Actos
Acyclovir
Adderall
Albuterol
Allegra
Altase
Amaryl
Amiodarone
Amoxycillin
Atenolol
Augmentin
Bactroban
Buspar
Captopril
Carbamazepine
Cefzil
Celebrex
Cipro
Clonidin
Coumadin
Cozar
Crestor
Depakote
Detrol
Diclofenac
Dilantin
Diovan
Effexor
Flomax
Flonase
Furosamide
Glucophage
Glyburide
HCTZ
Humulin
Hydrocortisone
Lasix
Levaquin
Lipitor
Lisinopril
Lortab
Metformin
Methlyprednisolone
MS Contin
Nasacort
Novalog
Oxycodone
Pepcid
Plaquenil
Plavix
Prednisone
Premarin
Prempro
Protonix
Proventil
Prozac
Ritalin
Singular
Synthroid
Tetracycline
Topamax
Valium
Wellbutrin
Xanax
Zantac
Zestril
Zoloft
Other
None
Actos
Acyclovir
Adderall
Albuterol
Allegra
Altase
Amaryl
Amiodarone
Amoxycillin
Atenolol
Augmentin
Bactroban
Buspar
Captopril
Carbamazepine
Cefzil
Celebrex
Cipro
Clonidin
Coumadin
Cozar
Crestor
Depakote
Detrol
Diclofenac
Dilantin
Diovan
Effexor
Flomax
Flonase
Furosamide
Glucophage
Glyburide
HCTZ
Humulin
Hydrocortisone
Lasix
Levaquin
Lipitor
Lisinopril
Lortab
Metformin
Methlyprednisolone
MS Contin
Nasacort
Novalog
Oxycodone
Pepcid
Plaquenil
Plavix
Prednisone
Premarin
Prempro
Protonix
Proventil
Prozac
Ritalin
Singular
Synthroid
Tetracycline
Topamax
Valium
Wellbutrin
Xanax
Zantac
Zestril
Zoloft
Other
None
Actos
Acyclovir
Adderall
Albuterol
Allegra
Altase
Amaryl
Amiodarone
Amoxycillin
Atenolol
Augmentin
Bactroban
Buspar
Captopril
Carbamazepine
Cefzil
Celebrex
Cipro
Clonidin
Coumadin
Cozar
Crestor
Depakote
Detrol
Diclofenac
Dilantin
Diovan
Effexor
Flomax
Flonase
Furosamide
Glucophage
Glyburide
HCTZ
Humulin
Hydrocortisone
Lasix
Levaquin
Lipitor
Lisinopril
Lortab
Metformin
Methlyprednisolone
MS Contin
Nasacort
Novalog
Oxycodone
Pepcid
Plaquenil
Plavix
Prednisone
Premarin
Prempro
Protonix
Proventil
Prozac
Ritalin
Singular
Synthroid
Tetracycline
Topamax
Valium
Wellbutrin
Xanax
Zantac
Zestril
Zoloft
Other
None
Actos
Acyclovir
Adderall
Albuterol
Allegra
Altase
Amaryl
Amiodarone
Amoxycillin
Atenolol
Augmentin
Bactroban
Buspar
Captopril
Carbamazepine
Cefzil
Celebrex
Cipro
Clonidin
Coumadin
Cozar
Crestor
Depakote
Detrol
Diclofenac
Dilantin
Diovan
Effexor
Flomax
Flonase
Furosamide
Glucophage
Glyburide
HCTZ
Humulin
Hydrocortisone
Lasix
Levaquin
Lipitor
Lisinopril
Lortab
Metformin
Methlyprednisolone
MS Contin
Nasacort
Novalog
Oxycodone
Pepcid
Plaquenil
Plavix
Prednisone
Premarin
Prempro
Protonix
Proventil
Prozac
Ritalin
Singular
Synthroid
Tetracycline
Topamax
Valium
Wellbutrin
Xanax
Zantac
Zestril
Zoloft
Other
None
Actos
Acyclovir
Adderall
Albuterol
Allegra
Altase
Amaryl
Amiodarone
Amoxycillin
Atenolol
Augmentin
Bactroban
Buspar
Captopril
Carbamazepine
Cefzil
Celebrex
Cipro
Clonidin
Coumadin
Cozar
Crestor
Depakote
Detrol
Diclofenac
Dilantin
Diovan
Effexor
Flomax
Flonase
Furosamide
Glucophage
Glyburide
HCTZ
Humulin
Hydrocortisone
Lasix
Levaquin
Lipitor
Lisinopril
Lortab
Metformin
Methlyprednisolone
MS Contin
Nasacort
Novalog
Oxycodone
Pepcid
Plaquenil
Plavix
Prednisone
Premarin
Prempro
Protonix
Proventil
Prozac
Ritalin
Singular
Synthroid
Tetracycline
Topamax
Valium
Wellbutrin
Xanax
Zantac
Zestril
Zoloft
Other
Drug Allergies:
NKDA
Codeine
Penicillin
Sulfa
Other
Other Allergies:
Vitamins:
Over The Counter Medications:
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
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
Last Eye Exam:
1 year
2 years
3 years
Other
By Doctor:
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
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
Review of Systems
General:
none
fatigue
fever
loss of appetite
weight gain
weight loss
Other
Ear/Nose/Throat:
none
chronic cough
congestion
daytime drowsiness
dry throat / mouth
gasp while sleeping
headache
hearing problems
heavy snoring
morning headaches
runny nose
sinus problems
sleep apnea
tinnitus
toothache
Other
Skin:
none
acne
eczema
itching
psoriasis
rosacea
Other
Cardiovascular:
none
chest pain
heart disease
high cholesterol
hypertension
racing heartbeat
shortness of breath
swollen feet/ankles
vascular disease
Other
Respiratory:
none
asthma
cronchitis
cyanosis
emphysema
productive cough
shortness of breath
wheezing
Other
Musculoskeletal:
none
arthritis
decreased range of motion
muscle cramps
pain/tenderness
stiffness
swelling
weakness
Other
Psychiatric:
none
anxiety
depression
insomnia
obsessive/compulsive
paranoia
suicidal
violence
Other
Gastrointestinal:
none
abdominal pain
acid reflux
bloody stools
constipation
Crohn's disease
dark urine
diarrhea
gastric reflux (GERD)
IBS
jaundice
nausea
ulcer
vomiting
Other
Endocrine:
none
diabetes
hypothyroid
hyperthyroid
Other
Blood/Lymph:
none
anemia
bleeding gums
cuts slow to clot
easy bruising
hx of significant blood loss
nosebleeds
pale skin
pounding in ears
rapid heartbeat
shortness of breath
Other
Neurological:
none
balance problems
changes in senses
dementia
memory problems
muscle weakness
numbness, paralysis
personality changes
speech problems
tremors
vertigo
Other
Genitourinary:
none
impotence
jaundice
overactive bladder
painful urination
painful urination
underactive bladder
urgency in urination
urinary incontinence
Other
Immune:
none
asthma
hives
itching
mild allergy symptoms
redness
severe allergy symptoms
sneezing
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
Race:
White
Black or African American
Asian
Patient Declined to Specify
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Other Race
Other
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Unknown
Patient Declined to Specify
Other
Preferred Language:
English
French
German
Spanish
Other
Second Language:
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