Vision Eye Max - Online Patient Form

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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