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 Doctor	No Doctor Assigned Dr. Coleman, Jeff	Misc/Guardian
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 Vision Insurance

Insurance Information

Insurance Name:	None New Insurance New Insurance Always Care Avesis Avesis Medicare Block Vision Blue Cross Blue Shield (Availity) Cigna Vision Davis Eyemed Medicare Plan B MES Vision New Insurance NVA Spectera Superior Vision Tricare United Health Care VSP (Out of Network)
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 Medical Insurance

Insurance Information

Insurance Name:	None New Insurance New Insurance Always Care Avesis Avesis Medicare Block Vision Blue Cross Blue Shield (Availity) Cigna Vision Davis Eyemed Medicare Plan B MES Vision New Insurance NVA Spectera Superior Vision Tricare United Health Care VSP (Out of Network)
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:

Teritary

Insurance Information

Insurance Name:	None New Insurance New Insurance Always Care Avesis Avesis Medicare Block Vision Blue Cross Blue Shield (Availity) Cigna Vision Davis Eyemed Medicare Plan B MES Vision New Insurance NVA Spectera Superior Vision Tricare United Health Care VSP (Out of Network)
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:

Chief Complaint

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Chief Complaint

Reason for Visit:
Secondary Complaints:

Notes:

Review of Ocular System

Ocular History:
Eye Meds:

Last Eye Exam:

1 year 2 years 3 years Other

Doctor:

Dr Coleman Dr Marshall Doesn't Remember Never Lens Crafters EyeMasters Pearl Other

Family Ocular 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:	No Parents Siblings Grandparent Other

Primary Vision Correction:

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

Have back up glasses?

Yes No Other

Planning to get new glasses?

Yes No Other

Type of CLs worn in past:

None Disposable Conventional Colored RGP PMMA Other

Wear Time:

8 - 10 Hours All day Occ. Overnight Extended Other

Cleaner:

Optifree Clear Care Boston Renu Other

Disposal:

2 weeks monthly daily weekly yearly Other

Miscellaneous Imformation

Race:

American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Other

Ethnicity:

Non Hispanic or Latino Hispanic or Latino Other

Preferred Language:

English French German Spanish Other

NOTES:

Medical History

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Patient Medical History

Problems:

Good health Arthritis Asthma Diabetes HBP Headaches Heart Condition HX Of Drug/Alcohol Abuse Inflammatory Bowel Disease Smoking Seizure Disorder Thyroid Disease Preg "Now" Nursing Diagnosed As HIV+ Other	Diabetes HBP Heart disease Cancer Arthritis Lupus Kidney Thyroid Back Problems Other	Athritis Diabetes HBP Heart Disease Cancer Lupus Kidney Disease Thyroid Disease Back Problems Other
Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Thyroid Back Problems Other	Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Thyroid Disease Back Problems Other	Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Disease Thyroid Back Problems Other

Injuries, Surgeries, Hospitalization:

Pregnant Or Nursing:

No Yes Unsure Other

Recent Tetanus Shot:

Yes No Other

Notes:

Primary Care Physcian:

Doesn't Have One Doesn't Remember None Cartrett Wilson Chin-Ha Other

Last Visit:

1 week 1 month 3 months 6 months 1 year 2 years Other

Reason For Visit:

Check up Annual Other

Current Medications:             No current meds	Drug Allergies:             No known drug allergies

Over The Counter Meds:

None Asprin Acetomenophin Ibuprofen Other

Vitamins:

None A E C Zinc Xanten Lutein Other

Family Medical History

None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid Other

Social History

Occupation:

Hobbies:

Smoking Status:	Never Smoker Current every day smoker Current some day smoker Former smoker Smoker, currernt status unknown Unknown if ever smoked Other	Type:	None Cigaretts Chewing Tobacco Other	How Long:
Alcohol:	No Yes Occasionally Socially Other	Type:	None Beer Wine Hard Liquor Other	How Long:
Illegal Drugs:	No Yes Other	Type:		How Long:
STD:	None Gonorrhea Syphilis Hepatitis HIV TB Other

Medications

Review of Systems

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

GENERAL: Fever, weight loss, weight gain, fatigue?	None Negative Other
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat	None Allergies Sinus Problems Chronic Cough Dry Throat / Mouth Hard of Hearing Other
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease	None Vascular Disease HBP Heart Surgery Other
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD	None Asthma Bronchitis Emphysema COPD Other
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence	None painful urination frequent urination impotence yellow jaundice Other
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury	None joint pain stiffness swelling cramps arthritis Other
SKIN: growths, rashes, acne	None pimples, warts growths rash Other
NEUROLOGICAL: Headaches, migraines, seizures	None numbness, paralysis headache seizures migraines Other
PSYCHIATRIC: Depression, Anxiety, Insomnia	None anxiety depression insomnia Other
ENDORCRINE: Thyroid, Diabetes	None diabetes hypothyroid hyperthoyroid Other
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems	None bleeding cholestrolemia anemia Other
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus	None sneezing swelling redness itching hives lupus Other
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux	None Diarrhea Constipation Ulcer Acid Reflux Other

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