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Demographics

Title First Last MI Suffix Nickname

Address: City: State/ZipCode CO

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. Forrest, Larry Dr. Gabriel, Gina Dr. Blackwood, Clark Dr. Wray, Jaclyn Dr. Potter, Rachel Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix

Address

City	State	ZipCode
	CO

Home Phone:
Work Phone:

Vision Plan 1

Insurance Information

Insurance Name:	None 1ST HEALTH AARP AARP MEDICARE COMPLETE AETNA AETNA MEDICARE HMO AETNA MEDICARE PPO AETNA VISION (PART OF EYE-MED) AMERICAN CONTINENTAL INSURANCE AMERICAN FAMILY AMERICAN INSURANCE ADMINISTRATORS AMERICAN REPUBLIC AMERITUS ANTHEM AO SAFETY ARETE ASSURANT BANNER HEALTH BERTHOUD VISION FOR LIFE BLUE CROSS/BLUE SHIELD BLUE VIEW BONDED BUSINESS SERVICES BOULDER COUNTY SOCIAL SERVICES CARE CREDIT CEBT (PART OF UNITED HEALTHCARE) CIGNA COFINITY DAVIS VISION EYE MED GEHA GOLDEN RULE HARTFORD HUMANA HUMANA GOLD MEDICARE HUMANA MEDICARE PPO HUMANA PFFS MEDICARE HYND BLIND FUND IMAGINE INFANT SEE KAISER LASIK MEDICAID MEDICARE MERITAN (PART OF GREAT WEST) METLIFE MUTUAL OF OMAHA NONE OPTUM RAILROAD MEDICARE ROCKY MOUNTAIN HEALTH PLAN STANDARD LIFE STATE FARM TRICARE UFCW UMR UNITED HEALTHCARE UNITED HEALTHCARE VISION UNITED MINE WORKERS MEDICARE USAA VISION SERVICE PLAN WILL CALL
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:

Vision Plan 2

Insurance Information

Insurance Name:	None 1ST HEALTH AARP AARP MEDICARE COMPLETE AETNA AETNA MEDICARE HMO AETNA MEDICARE PPO AETNA VISION (PART OF EYE-MED) AMERICAN CONTINENTAL INSURANCE AMERICAN FAMILY AMERICAN INSURANCE ADMINISTRATORS AMERICAN REPUBLIC AMERITUS ANTHEM AO SAFETY ARETE ASSURANT BANNER HEALTH BERTHOUD VISION FOR LIFE BLUE CROSS/BLUE SHIELD BLUE VIEW BONDED BUSINESS SERVICES BOULDER COUNTY SOCIAL SERVICES CARE CREDIT CEBT (PART OF UNITED HEALTHCARE) CIGNA COFINITY DAVIS VISION EYE MED GEHA GOLDEN RULE HARTFORD HUMANA HUMANA GOLD MEDICARE HUMANA MEDICARE PPO HUMANA PFFS MEDICARE HYND BLIND FUND IMAGINE INFANT SEE KAISER LASIK MEDICAID MEDICARE MERITAN (PART OF GREAT WEST) METLIFE MUTUAL OF OMAHA NONE OPTUM RAILROAD MEDICARE ROCKY MOUNTAIN HEALTH PLAN STANDARD LIFE STATE FARM TRICARE UFCW UMR UNITED HEALTHCARE UNITED HEALTHCARE VISION UNITED MINE WORKERS MEDICARE USAA VISION SERVICE PLAN WILL CALL
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:

Primary Medical

Insurance Information

Insurance Name:	None 1ST HEALTH AARP AARP MEDICARE COMPLETE AETNA AETNA MEDICARE HMO AETNA MEDICARE PPO AETNA VISION (PART OF EYE-MED) AMERICAN CONTINENTAL INSURANCE AMERICAN FAMILY AMERICAN INSURANCE ADMINISTRATORS AMERICAN REPUBLIC AMERITUS ANTHEM AO SAFETY ARETE ASSURANT BANNER HEALTH BERTHOUD VISION FOR LIFE BLUE CROSS/BLUE SHIELD BLUE VIEW BONDED BUSINESS SERVICES BOULDER COUNTY SOCIAL SERVICES CARE CREDIT CEBT (PART OF UNITED HEALTHCARE) CIGNA COFINITY DAVIS VISION EYE MED GEHA GOLDEN RULE HARTFORD HUMANA HUMANA GOLD MEDICARE HUMANA MEDICARE PPO HUMANA PFFS MEDICARE HYND BLIND FUND IMAGINE INFANT SEE KAISER LASIK MEDICAID MEDICARE MERITAN (PART OF GREAT WEST) METLIFE MUTUAL OF OMAHA NONE OPTUM RAILROAD MEDICARE ROCKY MOUNTAIN HEALTH PLAN STANDARD LIFE STATE FARM TRICARE UFCW UMR UNITED HEALTHCARE UNITED HEALTHCARE VISION UNITED MINE WORKERS MEDICARE USAA VISION SERVICE PLAN WILL CALL
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 Medical

Insurance Information

Insurance Name:	None 1ST HEALTH AARP AARP MEDICARE COMPLETE AETNA AETNA MEDICARE HMO AETNA MEDICARE PPO AETNA VISION (PART OF EYE-MED) AMERICAN CONTINENTAL INSURANCE AMERICAN FAMILY AMERICAN INSURANCE ADMINISTRATORS AMERICAN REPUBLIC AMERITUS ANTHEM AO SAFETY ARETE ASSURANT BANNER HEALTH BERTHOUD VISION FOR LIFE BLUE CROSS/BLUE SHIELD BLUE VIEW BONDED BUSINESS SERVICES BOULDER COUNTY SOCIAL SERVICES CARE CREDIT CEBT (PART OF UNITED HEALTHCARE) CIGNA COFINITY DAVIS VISION EYE MED GEHA GOLDEN RULE HARTFORD HUMANA HUMANA GOLD MEDICARE HUMANA MEDICARE PPO HUMANA PFFS MEDICARE HYND BLIND FUND IMAGINE INFANT SEE KAISER LASIK MEDICAID MEDICARE MERITAN (PART OF GREAT WEST) METLIFE MUTUAL OF OMAHA NONE OPTUM RAILROAD MEDICARE ROCKY MOUNTAIN HEALTH PLAN STANDARD LIFE STATE FARM TRICARE UFCW UMR UNITED HEALTHCARE UNITED HEALTHCARE VISION UNITED MINE WORKERS MEDICARE USAA VISION SERVICE PLAN WILL CALL
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

ASSESSMENT:________________________________________________________________________________________________________________

Hobbies:

Primary Vision Correction: Contacts Bifocals Contacts - Mono None Progressives Single Vision Trifocals Glasses Occupation: retired student unemployed

A1C Unknown <6.5 6.6 6.7 6.8 6.9 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 7.9 8.0 8.1 8.2 8.3 8.4 8.5 >8.6 Glare at night? Yes No Sometimes Dry/Itchy Eyes Yes Dry No Dry Occasional Dry Yes Itchy No Itchy Occasional Itchy

Interested in Laser Vision Correction? Yes Possibly interested No Interested In Contact Lenses? Yes No Possibly
Back up glasses? Yes No Computer glasses? Yes No Interested Sunglasses? Yes No Non-prescription

PERSONAL MEDICAL HISTORY:_________________________________________________________________________________________________

Eye Hx: Surg.,Injury,Cats, Ambly.,Floaters, GL, Strab., Retinal None Blepheroplasty Cataract - OU Cataract - OD Cataract - OS Conjunctivitis Corneal Abrasion Glaucoma Itching Lazy Eye Metal in Eye Ptosis Redness Retinal Detachment Watering Primary Care Physician:
Last Eye Doctor: Costco Cascade Eye Center Lenscrafters Wal-Mart Shopko Sears Eye Meds: None Artificial Tears Acular Bacitracin ung Betoptic-S .25% Betoptic .5% Betagan Erythromycin FML FML Forte Gentamicin Lotemax Neosporin Ocupress Pataday Pilo Gel Propine Polytrim Pred Mild Pred Forte Patanol Rewetting drops Soothe Systane Timoptic .25% Timoptic .5% Tobradex Travatan Z Vigamox Visine Voltaren Xalatan Zylet Allergies: Drugs, Seasonal NKDA Aspirin Cephalosporins Codeine Iodine Keflex Latex Novacaine Nsaids Nuts Penicillan Group Percocet Quinolones Group Seasonal allergies Shellfish Silicone Sulfa Group Tetanus NKDA Vicodin

Systemic Meds:


Med Hx: Seizures, Stroke, Concussion, MVA, etc.

Smoke None 1 pack/day 1/2 pack/day Alcohol None socially <2 drinks/day >2 drinks/day Drugs None Cocaine Marijuana Pregnant No

NOTES/SOCIAL HISTORY: Social Hx: Denies any tobacco, alcohol and drug use Pach: Pt drinks socially. Denies smoking and drug use.

REVIEW OF SYSTEMS:_________________________________________________________________________________________________

Cardiovascular (HTN,Cholesterol,stroke,heart disease,vascular disease):	none racing congestive heart failure coronary artery disease high blood pressure irregular heartbeat high cholesterol
Urinary (bladder,prostate,incontinence):	None bladder prostate incontinence
Neurological (MS,Tumor,Epilepsy,Cerebral Palsy):	none MS Tumor Epilepsy Cerebral Palsy
Hematological (Anemia,Leukemia):	none Leukemia Anemia
Dermatologic (Eczema,Rosacea,Psoriasis):	none Eczema Rosacea Psoriasis
Endocrine (Diabetes,Thyroid,Hormonal):	none Non-Insulin Dependent Diabetes Insulin Dependent Diabetes Hyperthyroid Hypothyroid Hormonal Dysfunction
Ocular (Glaucoma,Macular Deg.,Detachement):	None Glaucoma Macular Degeneration Detached Retina Cataracts
Musculoskeletal (Arthritis,fibromyalgia,muscle dystrophy):	none Osteoarthritis Fibromyalgia Muscular Dystrophy Ankylosing Spondylitis
Gastrointestinal (acid refulx,colitis,Crohn's):	None Crohn's Colitis
Respiratory (asthma,bronchitis,emphysema,COPD):	none Asthma Bronchitis COPD Emphysema
Psychiatric (ADHD,Depression,Schizophrenia):	none ADHD Depression Schizophrenia
Immunologic (AIDS,HIV,Lupus,STDs):	none AIDS or HIV Rheumatoid Arthritis Lupus Neurofibromatosis
Ears, Nose, Throat (Hearing,URI):	None Hearing Loss Upper Respiratory Infection Congestion

FAMILY HISTORY:_________________________________________________________________________________________________

	Yes/No	Who
Retinal Detachment
High Blood Pressure
Diabetes
Cancer
Heart Disease
Thyroid Disease

	Yes/No	Who
Blindness
Cataracts
Glaucoma
Crossed Eyes
Macular Degeneration
Lupus

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