Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Address:
City:		State/ZipCode	TX

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. Fuller, Bridgette Dr. Garvom, Geesala Dr. Stengel, Clint Dr. Sturm, Mark	Misc/Guardian
Primary Care Doctor

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Address

City	State	ZipCode
	TX

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None **No Medical Insurance** AARP (Supplement) Advantica Aetna (PPO) Aetna Medicare Advantage Always Care Avesis Baylor Scott & White BCBS (Anthem) BCBS Medicare Advantage BCBS of Texas (HMO) BCBS of Texas (PPO) Boon Chapman Celtic Individual Health Cigna Davis Vision Eyemed Eyetopia Fortified Galaxy Health Network GEHA Heritage Vision Plan - Heritage Vision Plan Humana (HMO) Humana Medicare Advantage (HMO) Humana PPO Ideal Care (Sendero) Medicaid (Baylor S&W) Medicaid (BCBS) Medicaid (Not Specified) Medicaid (Sendero) Medicaid (Superior Foster) Medicaid (Superior Health) Medicaid (Traditional) Medicare Meritain MES Vision Mutual of Omaha (supp only) Other (Not Listed Otherwise) Sana Benefits Scott & White Health Plan Sight Savers Spectera Superior Ambetter Superior Health Plan Superior Vision Superior Vision (SW Select - OON) TML Multistate Tricare Tricare For Life United Health Care All Savers United HealthCare UnitedHealthCare Medicare Advantage VBA VSP Wellcare Texas Medicare Advantage WellMed
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 **No Medical Insurance** AARP (Supplement) Advantica Aetna (PPO) Aetna Medicare Advantage Always Care Avesis Baylor Scott & White BCBS (Anthem) BCBS Medicare Advantage BCBS of Texas (HMO) BCBS of Texas (PPO) Boon Chapman Celtic Individual Health Cigna Davis Vision Eyemed Eyetopia Fortified Galaxy Health Network GEHA Heritage Vision Plan - Heritage Vision Plan Humana (HMO) Humana Medicare Advantage (HMO) Humana PPO Ideal Care (Sendero) Medicaid (Baylor S&W) Medicaid (BCBS) Medicaid (Not Specified) Medicaid (Sendero) Medicaid (Superior Foster) Medicaid (Superior Health) Medicaid (Traditional) Medicare Meritain MES Vision Mutual of Omaha (supp only) Other (Not Listed Otherwise) Sana Benefits Scott & White Health Plan Sight Savers Spectera Superior Ambetter Superior Health Plan Superior Vision Superior Vision (SW Select - OON) TML Multistate Tricare Tricare For Life United Health Care All Savers United HealthCare UnitedHealthCare Medicare Advantage VBA VSP Wellcare Texas Medicare Advantage WellMed
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 **No Medical Insurance** AARP (Supplement) Advantica Aetna (PPO) Aetna Medicare Advantage Always Care Avesis Baylor Scott & White BCBS (Anthem) BCBS Medicare Advantage BCBS of Texas (HMO) BCBS of Texas (PPO) Boon Chapman Celtic Individual Health Cigna Davis Vision Eyemed Eyetopia Fortified Galaxy Health Network GEHA Heritage Vision Plan - Heritage Vision Plan Humana (HMO) Humana Medicare Advantage (HMO) Humana PPO Ideal Care (Sendero) Medicaid (Baylor S&W) Medicaid (BCBS) Medicaid (Not Specified) Medicaid (Sendero) Medicaid (Superior Foster) Medicaid (Superior Health) Medicaid (Traditional) Medicare Meritain MES Vision Mutual of Omaha (supp only) Other (Not Listed Otherwise) Sana Benefits Scott & White Health Plan Sight Savers Spectera Superior Ambetter Superior Health Plan Superior Vision Superior Vision (SW Select - OON) TML Multistate Tricare Tricare For Life United Health Care All Savers United HealthCare UnitedHealthCare Medicare Advantage VBA VSP Wellcare Texas Medicare Advantage WellMed
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:

Supplemental

Insurance Information

Insurance Name:	None **No Medical Insurance** AARP (Supplement) Advantica Aetna (PPO) Aetna Medicare Advantage Always Care Avesis Baylor Scott & White BCBS (Anthem) BCBS Medicare Advantage BCBS of Texas (HMO) BCBS of Texas (PPO) Boon Chapman Celtic Individual Health Cigna Davis Vision Eyemed Eyetopia Fortified Galaxy Health Network GEHA Heritage Vision Plan - Heritage Vision Plan Humana (HMO) Humana Medicare Advantage (HMO) Humana PPO Ideal Care (Sendero) Medicaid (Baylor S&W) Medicaid (BCBS) Medicaid (Not Specified) Medicaid (Sendero) Medicaid (Superior Foster) Medicaid (Superior Health) Medicaid (Traditional) Medicare Meritain MES Vision Mutual of Omaha (supp only) Other (Not Listed Otherwise) Sana Benefits Scott & White Health Plan Sight Savers Spectera Superior Ambetter Superior Health Plan Superior Vision Superior Vision (SW Select - OON) TML Multistate Tricare Tricare For Life United Health Care All Savers United HealthCare UnitedHealthCare Medicare Advantage VBA VSP Wellcare Texas Medicare Advantage WellMed
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 complete all entries below, then push "submit" button on next tab to submit information to our office **

**Current/Past Eye Conditions** (check all that apply)

Vision Loss	Gritty Feeling	Infection	Diabetic Retinopathy
Blurry Vision	Itching	Stie	Glaucoma
Distorted Vision	Excess Watering	Flashes	Macular Degeneration
Dry Eyes	Light Sensitivity	Floaters	Retinal Detachment
Redness	Burning	Tired Eyes	Double Vision
Discharge	Eye Pain	Cataracts

 Any other eye problems, conditions? Explain in space below.
(Night-time blurriness or halos, dry eyes, itchy eyes, computer eye strain, lumps or bumps,
eye pain or discomfort)                         
 



List any Ocular History  (Lasik, eye surgery, eye trauma, lazy eye, cataract surgery)


List any Allergies (Seasal, allergies to drugs, foods, medications)


Surgeries/Injuries (Heart surgery, trauma to head, major accidents, etc)


Medications and Eye Drops (list any medications currently taking, including eye drops)




**Social History **

Alcohol use (Y/N)     Yes No

Pregnant/Nursing? (Y/N)        No Yes

Smoking         Current Smoker- Every Day Current Smoker- Some Days Former Smoker Never Smoked  

Rec Drugs (Y/N)      No Yes

Drives (Y/N)             Yes No

Hobbies                   
 
 

**Personal History** (select all that apply to you)

Gastrointestinal	Neurological	Respiratory	Genitourinary
Colitis	Headaches	Asthma	Bladder Problems
Crohns Dz	Seizures	Bronchitis	Kidney Problems
Ulcers	Migraines	Emphysema	STD's
Constipation	Multiple Sclerosis
Diarrhea
Constitutional	Endocrine	Cardiovascular	Allergic/Immune
Fever	Type I Diabetes	Heart Dz	Drug Allergies
Weight loss/Gain	Type II Diabetes	High Blood Pressure	Seasonal Allergies
Fatigue	Thyroid Dysfunction	High Cholesterol	Arthritis
Trauma
Skin	Ears/Nose/Throat	Musculoskeletal	Lymph/Blood
Eczema	Allergies	Osteoarthritis	Anemia
Rosacea	Dry Mouth	Fribromyalgia	Bleeding Problems
Psoriasis	Sinus Congestion	Ankylosing Spond.	Leukemia

Other

**Family Medical History ** (Check if any family members have or have had condition. Specify which family member in box open box next to condition)

Blindness	No Grandparent Parent Sibling Aunt/Uncle Child Unknown		Cancer	No Grandparent Parent Sibling Aunt/Uncle Child Unknown
Cataracts	No Grandparent Parent Sibling Aunt/Uncle Child Unknown		Diabetes	No Grandparent Parent Sibling Aunt/Uncle Child Unknown
Macular Degen	No Grandparent Parent Sibling Aunt/Uncle Child Unknown		Heart Dz	No Grandparent Parent Sibling Aunt/Uncle Child Unknown
Glaucoma	No Grandparent Parent Sibling Aunt/Uncle Child Unknown		High BP	No Grandparent Parent Sibling Aunt/Uncle Child Unknown
Retinal Detach	No Grandparent Parent Sibling Aunt/Uncle Child Unknown		Kidney Dz	No Grandparent Parent Sibling Aunt/Uncle Child Unknown
Crossed Eyes	No Grandparent Parent Sibling Aunt/Uncle Child Unknown		Arthritis	No Grandparent Parent Sibling Aunt/Uncle Child Unknown
Thyroid Dz	No Grandparent Parent Sibling Aunt/Uncle Child Unknown		Lupus	No Grandparent Parent Sibling Aunt/Uncle Child Unknown

Submit

Thank you for taking the time to fill out our online History Questionnaire form.

You may click on each tab above to review the information you have provided.

Please be sure you have filled out BOTH the Demographics tab AND the Medical History tab and any applicable insurance tabs before clicking submit.

Please make sure to click on the "Submit Date" button below to securely submit your information.

Is is OK to call you for your yearly exam reminder? Yes, you may call me for this reminder No, please do not call me for this reminder

Submit Data