Online Patient Form

Demographics

Patient Information

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

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:
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 Care Doctor

Billing Information

Is The Billing Address the Same?

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

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:

Primary Insurance

Insurance Information

Insurance Name:	None Advantica Aetna Health Plans Avesis Blue Cross and Blue Shield of Texas Central United Life Cigna (out of network) Davis Vision Eyemed Guardian Health for All Humana Medicaid (AmeriGroup Managed Care Program) Medicaid (SCWTX Right Care) Medicaid (standard) Medicaid (Superior Managed Care) Medicare of Texas MES Vision Southern Operators Health Fund Spectera- Vision Only Superior Vision Services United HealthCare of all states VSP
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

Insurance Information

Insurance Name:	None Advantica Aetna Health Plans Avesis Blue Cross and Blue Shield of Texas Central United Life Cigna (out of network) Davis Vision Eyemed Guardian Health for All Humana Medicaid (AmeriGroup Managed Care Program) Medicaid (SCWTX Right Care) Medicaid (standard) Medicaid (Superior Managed Care) Medicare of Texas MES Vision Southern Operators Health Fund Spectera- Vision Only Superior Vision Services United HealthCare of all states VSP
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

Chief Complaint

blurrred vision distance vision blurry near vision blurry vision blurry distance and near wants to be fitted for contacts needs new glasses red eye pain in eye loss of vision injury to eye itching burning stinging dry eyes Diabetic eye exam broken glasses Lost RX failed screening at school failed screening at pediatrician's office Physician directed eye exam Complete eye exam to rule out problems needs more contacts Other

Secondary Complaints:

Eye History

None Itching Burning, Stinging Red Floaters Flashes Of Light Eye Injuries Eye Surgery Amblyopia Strabismus Cataracts Glaucoma Retinal Disorders Other

Eye Medications:

None Cromolyn NA 4% Visine Patanol Xalatan Travatan rewetting drops Elestat Vigamox Alphagan Refresh Theratears Genteal Pred Forte Lotemax Alrex Systane Blink Other

Last Eye Exam:

less than 1 year 1 year 2 years 3 years Other

Primary Vision Correction:

None Glasses-Full Time Glasses-Readers Only Contacts - Soft RGPs PMMA OTC readers Other

Type of Contact Lens worn in past:

None 1 Day Acuvue Moist Acuvue 2 Acuvue Advance Acuvue Oasys Acuvue Oasys 1-Days Air Optix Aqua Air Optix Colors Air Optix Night and Day Avaira Biofinity Biomedics 55 Premier Dailes AquaComfort Plus Dailies Total 1 Focus Dailies Proclear Proclear 1-Day PureVision SofLens Soflens 38 SofLens Daily Hard Don't Know Other

How often do you change your contacts:

daily 2 weeks monthly weekly yearly Other

Race:

White Black or African American Asian Patient Declined to Specify American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Other Race Other

Ethnicity:

Not Hispanic or Latino Hispanic or Latino Other Patient Declined to Specify Other

Preferred Language:

English French German Spanish Other

Family Eye History Glaucoma:

No Parents Sibling Grandparent Other

Cataracts:

No Parents Siblings Grandparent Other

Macular Degeneration:

No Parents Siblings Grandparent Other

Retinal Detachment:

No Parents Siblings Grandparent Other

Crossed / Lazy Eye:

No Parents Siblings Grandparent Other

General Medical History: EAR, NOSE, THROAT: None Allergies Sinus Problems Chronic Cough Dry Throat / Mouth Hard of Hearing Other CARDIOVASCULAR: None Vascular Disease HBP Heart Surgery Other RESPIRATORY: None Asthma Bronchitis Emphysema COPD Other GENITAL, KIDNEY, BLADDER: None painful urination frequent urination impotence yellow jaundice Other MUSCLES, BONES, JOINTS: None joint pain stiffness swelling cramps arthritis Other SKIN: None pimples, warts growths rash Other NEUROLOGICAL: None numbness, paralysis headache seizures migraines Other PSYCHIATRIC: None anxiety depression insomnia Other ENDORCRINE: None diabetes hypothyroid hyperthoyroid Other BLOOD/LYMPH: None bleeding cholestrolemia anemia Other ALLERGIC / IMMUNOLOGIC: None sneezing swelling redness itching hives lupus Other GASTROINTESTINAL: None Diarrhea Constipation Ulcer Acid Reflux Other Pregnant Or Nursing: No Yes Unsure Other Recent Tetanus Shot: unknown Yes No Other Last Visit Primary Care Visit: 1 week 1 month 3 months 6 months 1 year 2 years greater than 3 years Other Reason For Last Primary Care Visit: Check up Annual Specific Other Injuries, Surgeries, Hospitalization

History of disease in your family:

Occupation:

Student Police officer Teacher Nurse Salesman Firefighter Engineer Other

Hobbies:

None Art Baseball Astronomy Boating Basketball Cooking Crafts Dancing Diving Football Fishing Golf Gardening Horseback Riding Hunting Models Needlepoint Painting Photography Piano Reading Running Roller Blading Softball Sewing Skiing Soccer Swimming Tennis Video Games Woodworking Other

Smoking Status

Never smoker (<100 cigs equiv) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Current every day smoker Unknown if ever smoked Other

Type:

None Cigaretts Chewing Tobacco Other

If you do smoke, how long have you smoked?:

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