Vision Eye Max
-
Online Patient Form
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are required.
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Demographics
Patient Information
Title
Last
First
MI
Suffix
Nickname
Mrs.
Mr.
Ms.
Dr.
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
ZipCode:
*
Home Phone:
Email
*
Cell Phone:
Preferred Contact:
Text Message
Cell Phone
Home Phone
Work Phone
Email
Work Phone:
Recieve Texts?:
Yes, send me texts for all notifications/reminders
No, please do not send any texts!
Sex
Male
Female
Occupation
Birthday (mm/dd/yyyy)
Employment Status
Employed
Full-Time Student
Part-Time Student
SSN (###-##-####)
Employer / School
Marital Status
Annulled
Divorced
Domestic partner
Interlocutory
Legally Separated
Married
Never Married
Polygamous
Widowed
Misc/Guardian
Billing Information
Is The Billing Information the Same?
Title
Last
First
MI
Suffix
Mrs.
Mr.
Ms.
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:
Medical Insurance
Insurance Information
Insurance Name:
No Insurance / Self Pay
Unknown
Aetna
Blue Cross Blue Shield TX
Cigna
Coventry Health Care
Humana VCP
Medicare Supplement
Medicare TX
Memorial Hermann (Commercial)
Memorial Hermann Medicare
Memorial Hermann Medicare (Advantage Pack)
UMR
United Health Care
Wellcare
VSP Signature
VSP Choice
VSP Exam Plus
EyeMed
National Vision Administrators
Vision Benefits Of America
MES Vision
Alwayscare Vision
Avesis
Spectera
Superior Vision
Davis Vision Discount
Insurance Plan:
Insurance ID:
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:
Vision Insurance
Insurance Information
Insurance Name:
No Insurance / Self Pay
Unknown
VSP Signature
VSP Choice
VSP Exam Plus
EyeMed
National Vision Administrators
Vision Benefits Of America
MES Vision
Alwayscare Vision
Avesis
Spectera
Superior Vision
Davis Vision Discount
Aetna
Blue Cross Blue Shield TX
Cigna
Coventry Health Care
Humana VCP
Medicare Supplement
Medicare TX
Memorial Hermann (Commercial)
Memorial Hermann Medicare
Memorial Hermann Medicare (Advantage Pack)
UMR
United Health Care
Wellcare
Insurance Plan:
Insurance ID:
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
Reason for visit:
How did you hear about us?
Insurance
Friends/Family
Google
Facebook
Instagram
Walk-by/Drive-by
Yelp
Other
Ocular History
Ocular Diseases/Injuries:
Ocular Surgery:
Eye Drops/Meds:
Last Eye Exam:
1 year
2 years
Other
Last Eye Doctor/Office:
Primary Vision Correction:
None
Glasses-Full Time
Glasses-Distance Only
Glasses-Near Only
Contacts-Soft
OTC readers
Other
Want new glasses?
Yes
No
Type of CLs worn in past:
None
Daily
2 Weeks
Monthly
Colored
Other
CL Solutions Used:
Biotrue
OptiFree Pure Moist
Clear Care
Other
Average CL Wear Time:
8 - 10 Hours
All day
Extended/Overnight
Other
CL Replace/Toss schedule:
daily
weekly
monthly
Other
Medical History
Last Health Exam:
less than 3 months
3-6 months
6-12 months
1-2 years
Other
Primary Care Physician:
Medications:
No current medications
Allergies:
No known drug allergies
Vitamins/Supplements:
Are you pregnant or nursing?
No
Yes
Unsure
Review of Systems
General (fatigue, fever, weight loss/gain, etc.)
Ear, nose, and throat (chronic cough, dry mouth, runny nose, congestion, etc.)
Cardiovascular (heart disease, high cholesterol, hypertension, vascular disease, etc.)
Respiratory (asthma, brochitis, emphysema, etc.)
Genital, kidney, and bladder (kidney problems, impotence, painful urination, etc.)
Muscles, bones, and joints (arthritis, pain, tenderness, etc.)
Gastrointestinal (Crohn's Disease, irritable bowel syndrome, GERD, acid reflux, etc.)
Skin (eczema, itching, rosacea, psoriasis, etc.)
Neurological (dementia, paralysis, multiple sclerosis, seizures, etc.)
Psychiatric (ADHD, anxiety, depression, paranoia, etc)
Endocrine (type 1 diabetes, type 2 diabetes, hyperthyroid, hypothyroid, etc.)
Blood/lymph (anemia, bleeding disorders, shortness of breath, etc.)
Allergic/immunologic (hives, seasonal, etc.)
Others
Family History
Ocular History
Medical History
Glaucoma:
None
Mother
Father
Sibling
Grandparent
Other
Diabetes:
None
Mother
Father
Sibling
Grandparent
Other
Cataracts:
None
Mother
Father
Sibling
Grandparent
Other
Hypertension:
None
Mother
Father
Sibling
Grandparent
Other
Macular Degeneration:
None
Mother
Father
Sibling
Grandparent
Other
High Cholesterol:
None
Mother
Father
Sibling
Grandparent
Other
Retinal Detachment:
None
Mother
Father
Sibling
Grandparent
Other
Thyroid:
None
Mother
Father
Sibling
Grandparent
Other
Crossed / Lazy Eye:
None
Mother
Father
Sibling
Grandparent
Other
Cardiovascular:
None
Mother
Father
Sibling
Grandparent
Other
Blindness:
None
Mother
Father
Sibling
Grandparent
Other
Cancer:
None
Mother
Father
Sibling
Grandparent
Other
Additional Info:
Additional Info:
Social History
Hobbies:
Smoking Status:
Current every day smoker
Current some day smoker
Former smoker
Smoker (current status unknown)
Unknown if ever smoked
Other
Type:
Cigarettes
Vapor
Other
Years:
less than 1 year
1-5 years
5+ years
Other
Alcohol:
No
Occasionally
1-3 / day
4+ / day
Other
Type:
Beer
Wine
Hard Liquor
Other
Years:
less than 1 year
1-5 years
5+ years
Other
Race:
Decline to Specify
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Ethnicity:
Decline to Specify
Hispanic or Latino
Not Hispanic or Latino
Preferred Language:
English
Spanish
Vietnamese
Other
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