Online Patient Form
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Demographics
Patient Information
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Address:
City:
State/ZipCode
GA
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
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
Email
Birthday
Occupation
Sex
Male
Female
Employment Status
Employed
Full-Time Student
Part-Time Student
Marital Status
Single
Married
Divorced
Widowed
Employer/School Name
Misc/Guardian
Is the Billing Address Different?
Billing Information
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Copy Address From Above
Address
City
State
ZipCode
GA
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
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:
Vision
Insurance Information
Insurance Name:
None
AAA DISCOUNT
AARP DISCOUNT
AARP MEDICARE SUPPLEMENTAL
AETNA
AETNA DISCOUNT
AETNA MEDICARE
BANKERS FIDELITY LIFE INSURANCE COMPANY(MEDICARE SUPP)
BCBS DISCOUNT ONLY
Blue Cross Blue Shield HMO
Blue Cross Blue Shield POS
Blue Cross Blue Shield PPO
CARE IMPROVEMENT PLUS
CIGNA-We do not file Out of Network Do Not Accept
COVENTRY DISCOUNT ONLY
Eyemed
Humana (VCP) Compbenefits
Humana Medical
Humana Medicare
INS. ADMINS SOLUTIONS (MC SUPPLEMENT)
Lions Club
MEDICA UNITED HEALTHCARE PLAN
Medicare Part B
MUTUAL OF OMAHA (MEDICARE SUPP)
NATL ELEVATOR INDUSTRY HEALTH BE (MEDICARE SUPPLEMENTAL)
NEW ERA LIFE INSURANCE (MC SUPPLEMENT)
Piedmont-Wellstar (We do not file this)
ROYAL NEIGHBORS OF AMERICA (MEDICARE SUPP)
Superior Vision
TRICARE DISCOUNT ONLY
TUFTS INSURANCE (MEDICARE SUPP)
UMR
UNITED AMERICAN INSURANCE COMP.(MC SUPP)
United Health Care
United Healthcare Medicare Solutions
VSP
WPS-TRICARE FOR LIFE (MEDICARE SUPPLEMENT)
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:
Employer/School:
Medical
Insurance Information
Insurance Name:
None
AAA DISCOUNT
AARP DISCOUNT
AARP MEDICARE SUPPLEMENTAL
AETNA
AETNA DISCOUNT
AETNA MEDICARE
BANKERS FIDELITY LIFE INSURANCE COMPANY(MEDICARE SUPP)
BCBS DISCOUNT ONLY
Blue Cross Blue Shield HMO
Blue Cross Blue Shield POS
Blue Cross Blue Shield PPO
CARE IMPROVEMENT PLUS
CIGNA-We do not file Out of Network Do Not Accept
COVENTRY DISCOUNT ONLY
Eyemed
Humana (VCP) Compbenefits
Humana Medical
Humana Medicare
INS. ADMINS SOLUTIONS (MC SUPPLEMENT)
Lions Club
MEDICA UNITED HEALTHCARE PLAN
Medicare Part B
MUTUAL OF OMAHA (MEDICARE SUPP)
NATL ELEVATOR INDUSTRY HEALTH BE (MEDICARE SUPPLEMENTAL)
NEW ERA LIFE INSURANCE (MC SUPPLEMENT)
Piedmont-Wellstar (We do not file this)
ROYAL NEIGHBORS OF AMERICA (MEDICARE SUPP)
Superior Vision
TRICARE DISCOUNT ONLY
TUFTS INSURANCE (MEDICARE SUPP)
UMR
UNITED AMERICAN INSURANCE COMP.(MC SUPP)
United Health Care
United Healthcare Medicare Solutions
VSP
WPS-TRICARE FOR LIFE (MEDICARE SUPPLEMENT)
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:
Employer/School:
Medical History
Referred By:
Walk-in
Insurance
Friend/Family
Website/Internet
Yellow Pages
Other
Referring Doctor:
Preferred Language:
English
Spanish
Other
Occupation:
Teacher
Engineer
Mechanic
Attorney
Doctor
Professor
IT
Plumber
Construction
Computer Technician
Dentist
Judge
Artist
Professional Athlete
Student
Pilot
Other
Computer Use:
1 hr/d
2-4 hrs/d
4-6 hrs/d
6-8 hrs/d
8-10 hrs/d
>10hrs/d
None
Other
Gender:
F
M
Other
Race:
White
African American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Asian
prefers not to answer
Other
Ethnicity:
Patient Declines
Not Hispanic or Latino
Hispanic or Latino
Other
Hobbies:
Height Feet:
1
2
3
4
5
6
Inches:
Weight:
PATIENT AND MEDICAL HISTORY:
Last Eye Exam:
1 Year Ago
2 Years Ago
3 Years Ago
>3 Years Ago
Unknown
Never
Other
Last Eye Doctor:
Dr. Bruce E. Reid & Associates
Unknown
Georgia Eye Specialists
Georgia Retina
OMNI Eye Care
Marietta Eye Clinic
Other
OCULAR HISTORY
SELF
RELATIVE
SELF
Cataracts
Dryness or pain in eyes
Glaucoma
Blurred Vision
Macular Degeneration
Double Vision
Retinal Disease
Eye Infection
Eye Disease
Eye Injury
Eye Surgery
Floaters New/worse?
Flashes New/worse?
Other ocular conditions/Notes:
Eye Meds:
None
Acular LS
Alrex Ophthalmic Suspension
Alphagan P
Artificial Tears
Azopt
Bepreve Opthalmic Solution
Besivance Opthalmic Suspension
Betoptic-S .25%
Betoptic .5%
Betagan
Cosopt
Erythromycin
FML
FML Forte
Gentamicin
Instalol Ophtalmic Solution
Lumigan
Gentamicin
Ocupress
Pilo Gel
Propine
Polytrim
Pred Mild
Pataday
Patanlol
Prolensa Ophthalmic Solution
Restasis Opthalmic Emulsion
Timpotic .25%
Timpotic .5%
Tobradex
Travatan
Voltaren
Xalatan
Zylet Ophthalmic Suspension
Last Medical Exam:
< 1 Year Ago
1 Year Ago
2 Years Ago
3 Years Ago
>3 Years Ago
Never
Unknown
Other
Primary Care Physician:
PCP Phone Number:
MEDICAL HISTORY
SELF
RELATIVE
SELF
RELATIVE
SELF
Diabetes
Asthma
Head Injury
High Blood Pressure
Thyroid
Nursing
Elevated Cholesterol
Cancer
Pregnant
Lung Disease
Migraines
Heart Disease
Headaches
Any other medical conditions/Notes:
Systemic Meds:
Allergies (Medications and Seasonal):
NKDA
Erythromycin
Iodine
Pollen
PCN
Sulfa
Codeine
Tetanus
Latex
Other
PERSONAL AND SOCIAL HISTORY:
Smoking Status
Smoker
Non-smoker
Other
Amount:
1 pack per day
Occasional/social
>1 pack/day
Other
Alcohol Status:
Yes
No
Other
Amount:
None
Daily
Once/Week
Social
Other
Primary Vision Correction:
Single Vision
Progressives
Bifocals
Trifocals
Contact Lenses
Contact Lenses-Multifocals
Contact Lenses-Monovision
None
Other
Age of current glasses:
1 Year
2 Years
3 Years
Unknown
Other
Sunspecs?
Yes
No
Other
Interested in Corrective Eye Surgery?
Yes
No
Other
H/o Contact Lenses Wear?
Yes
No
Other
Interested In Contact Lenses?
Yes
No
Maybe
Other
If no, why not?
Brand of CLs worn in the past:
AV Oasys
AV Oasys for Astigmatism
1-Day Acuvue TruEye
1 Day Acuvue Moist
1 Day Acuvue Moist for Astigmatism
Acuvue Oasys for Presbyopia
AV Advance
Acuvue Advance for Astigmatism
Acuvue 2
Acuvue 2 Colours
Air Optix Aqua
Air Optix for Astigmatism
Air Optix Aqua Multifocal
Air Optix N & D
Dailies ACP
Dailies Toric
Fresh Look
Fresh Look Toric
Focus Monthly
Biofinity
Biofinity Toric
Biofinity Multifocal
Proclear
Proclear Toric
Proclear Multifocal
Proclear 1-Day
Frequency 55 Toric
Frequency 55 Multifocal
Vertex Toric
Biomedics 55
Biomedics Toric
Purevision
Purevision Toric
Purevision Multi-focal
Purevision 2
Purevision 2 for Astigmatism
BioTrue One Day Lenses
SL Toric
Soflens Multifocal
Other
Replacement Frequency:
Daily
Weekly
Biweekly
Monthly
Yearly
Unknown
Other
Solution:
Opti-Free PureMoist
Revitalens
BioTrue
Opti-Free Replenish
Opti-Free Express
Complete
Renu
Saline
Unknown
Other
Drops?
Yes
No
Other
EW?
Yes
No
Other
How many nights/week?
None
1
2
3
4
5
6
7
Other
Back up specs for Contact Lenses?
Yes
No
Other
NOTES
Review of Systems
REVIEW OF SYSTEMS
DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?
GENERAL:
Fatigue
Weight gain
Weight loss
Chronic fever
None
CARDIOVASCULAR:
Heart surgery
Irregular Heartbeat
Chest Pain
None
EAR, NOSE, THROAT:
Hearing loss
Sore throat
Sinus
None
RESPIRATORY:
Asthma
Shortness of Breath
Bronchitis
Emphysema
COPD
None
GASTROINTESTINAL:
Heartburn
Vomiting
Abdominal pain
None
GENITOURINARY:
Kidney
Bladder/Urinary
Genital
None
MUSCULOSKELETAL:
Arthritis
Muscle Pain
Joint Pain
Head or neck injury
None
SKIN:
Growths
Rashes
Acne
Excessive Dryness
None
NEUROLOGICAL:
Headaches
Migraines
Seizures
Numbness
None
PSYCHIATRIC:
Depression
Anxiety
Insomnia
None
ENDOCRINE:
Diabetes
Thyroid
Problems with other glands
None
BLOOD/LYMPH:
Anemia
Cholesterol
Bleeding problems
None
ALLERGIC / IMMUNOLOGIC:
Lupus
Seasonal Allergies
Rheumatoid
AIDS
Allergy shots
None
NOTES:
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