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. Harvey, Rachel	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

Insurance Information

Insurance Name:	None AETNA Affinity Always Care ALWAYS CARE Ambassador Avesis Axis BCBS Block BLUECROSS BLUESHIELD Bright Health ChampVA CIGNA Cigna Healthspring Davis Vision EBPA EYEMED GHI GROUPON HealthSmart Benefit Solutions Healthspring Humana Choice IRON Iron ReHealth Vision Plan Medicaid Medicare NEXGEN8 OFFER Peehip PHYSICIANS MUTUAL Proctective Qual Choice SEIB Seniors First Southland SPECTERA Superior Vision Telapex Inc Transamerica Life TRICARE Ultimate Lens Package UMWA Unicare UNITED HEALTH CARE United oF Omaha Life Insurance VCP VISION BENFITS OF AMERICA Vision Care Affinity Plan Vision Choice VIVA HEALTH VSP
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 AETNA Affinity Always Care ALWAYS CARE Ambassador Avesis Axis BCBS Block BLUECROSS BLUESHIELD Bright Health ChampVA CIGNA Cigna Healthspring Davis Vision EBPA EYEMED GHI GROUPON HealthSmart Benefit Solutions Healthspring Humana Choice IRON Iron ReHealth Vision Plan Medicaid Medicare NEXGEN8 OFFER Peehip PHYSICIANS MUTUAL Proctective Qual Choice SEIB Seniors First Southland SPECTERA Superior Vision Telapex Inc Transamerica Life TRICARE Ultimate Lens Package UMWA Unicare UNITED HEALTH CARE United oF Omaha Life Insurance VCP VISION BENFITS OF AMERICA Vision Care Affinity Plan Vision Choice VIVA HEALTH VSP
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 AETNA Affinity Always Care ALWAYS CARE Ambassador Avesis Axis BCBS Block BLUECROSS BLUESHIELD Bright Health ChampVA CIGNA Cigna Healthspring Davis Vision EBPA EYEMED GHI GROUPON HealthSmart Benefit Solutions Healthspring Humana Choice IRON Iron ReHealth Vision Plan Medicaid Medicare NEXGEN8 OFFER Peehip PHYSICIANS MUTUAL Proctective Qual Choice SEIB Seniors First Southland SPECTERA Superior Vision Telapex Inc Transamerica Life TRICARE Ultimate Lens Package UMWA Unicare UNITED HEALTH CARE United oF Omaha Life Insurance VCP VISION BENFITS OF AMERICA Vision Care Affinity Plan Vision Choice VIVA HEALTH VSP
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:

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Chief Complaint

PURPOSE OF VISIT	REFEX DILEX FORIEGN BODY FLASHES/FLOATERS GLAUCCK POST OP RED EYE Other
CHIEF COMPLAINT

PATIENT OCULAR HISTORY: Injuries, Infections, Surgeries, Diseases	None Eye Surgery Amblyopia Itching Burning, Stinging Flashes Of Light Floaters Strabismus Cataracts Glaucoma Retinal Disorders Eye Injury (recent) Eye Injury (in past) Other
Eye Medications:	None Travatan Z Latanoprost Combigan Simbrinza Alphagan P Brimonidine Lumigan Timolol Betimol Cosopt Azopt Rhopressa Rocklatan Restasis Xiidra Ofloxacin Durezol Azelastine Olopatadine Acular Ketorolac Loteprednol Tobradex Polytrim Erythromycin Maxitrol Other

Primary Vision Correction:	None Glasses-Full Time Glasses-Readers Only Contacts - Soft RGPs Other	Last Eye Exam:	1 year 2 years 3 years Other	Doctor:	Dr. DeShon Doesn't Remember Never Other
Sunspecs?	Yes No Other	Computer glasses?	Yes No Other	Back up specs?	Yes No Other
Contact Lenses:	Acuvue Unknown Air Optix Biofinity Synergeyes RGP Other	Wear Time:	Full Time While Awake 8 - 10 Hours All day Occ. Overnight EW every night EW Occasionally Part Time 50% Part Time <50% Part Time >50% Weekends only Weekdays only Other	Disinfection:	Optifree Clear Care Boston Renu Other	Contact Lens Age:	unknown 1 day < 1 week 1 week 2 weeks 3 weeks 1 month Other

Family Ocular History

Glaucoma	No Grandparents Parents Sibling Other	Cataracts	No Grandparents Parents Siblings Other	Macular Degen	No Grandparents Parents Siblings Other
Retinal Detach	No Grandparents Parents Siblings Other	Strabismus	No Grandparents Parents Siblings Other

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Medical History

INJURY SURGERY HOSPITALIZATION		FAMILY MEDICAL HISTORY:	None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid Other
Pregnant Or Nursing	No Yes Unsure Other	PRIMARY CARE PHYSICIAN:	Doesn't Have One Doesn't Remember None Other

Social History

Occupation:	Admin. Construction Engineer Farmer Landscaping Lawyer Manufacturing Nurse Pilot Teacher Other	Hobbies:	Astronomy Art Baseball Boating Basketball Cooking Crafts Dancing Diving Football Fishing Golf Gardening Horseback Riding Hunting Models Needlepoint None Painting Photography Piano Reading Running Roller Blading Softball Sewing Skiing Soccer Swimming Tennis Video Games Woodworking Other
Tobacco	No Yes Other	Type	None Chewing Tobacco Cigarettes Cigars Pipe Other	How Long
Alcohol	No Occasionally Socially Rarely Once/week Every day Alcoholic Recovering Alcoholic 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

Medical History:	Diabetes High Blood Pressure Lupus Rheumatoid Arthritis Ulcerative Colitis Reiter's syndrome Pacemaker HIV+ Pregnant Nursing None Other
DRUG ALLERGY	NKDA Codeine Penicillin Sulfa Other

Medication 1	None Warfarin Atorvastatin Simvastatin Cetirizine Flexeril Lisinopril Losartan Amlodipine Allopurinol Maxzide Keflex Cellcept Trazodone Aspirin Trulicity Invokamet Jardiance Novolog Gabapentin Baclofen Other	Medication 2	None Warfarin Atorvastatin Simvastatin Cetirizine Flexeril Lisinopril Losartan Amlodipine Allopurinol Maxzide Keflex Cellcept Trazodone Aspirin Trulicity Invokamet Jardiance Novolog Gabapentin Baclofen Other	Medication 3	None Warfarin Atorvastatin Simvastatin Cetirizine Flexeril Lisinopril Losartan Amlodipine Allopurinol Maxzide Keflex Cellcept Trazodone Aspirin Trulicity Invokamet Jardiance Novolog Gabapentin Baclofen Other
Medication 4	None Warfarin Atorvastatin Simvastatin Cetirizine Flexeril Lisinopril Losartan Amlodipine Allopurinol Maxzide Keflex Cellcept Trazodone Aspirin Trulicity Invokamet Jardiance Novolog Gabapentin Baclofen Other	Medication 5	None Warfarin Atorvastatin Simvastatin Cetirizine Flexeril Lisinopril Losartan Amlodipine Allopurinol Maxzide Keflex Cellcept Trazodone Aspirin Trulicity Invokamet Jardiance Novolog Gabapentin Baclofen Other	Medication 6	None Warfarin Atorvastatin Simvastatin Cetirizine Flexeril Lisinopril Losartan Amlodipine Allopurinol Maxzide Keflex Cellcept Trazodone Aspirin Trulicity Invokamet Jardiance Novolog Gabapentin Baclofen Other
Medication 7	None Warfarin Atorvastatin Simvastatin Cetirizine Flexeril Lisinopril Losartan Amlodipine Allopurinol Maxzide Keflex Cellcept Trazodone Aspirin Trulicity Invokamet Jardiance Novolog Gabapentin Baclofen Other	Medication 8	None Warfarin Atorvastatin Simvastatin Cetirizine Flexeril Lisinopril Losartan Amlodipine Allopurinol Maxzide Keflex Cellcept Trazodone Aspirin Trulicity Invokamet Jardiance Novolog Gabapentin Baclofen Other	Medication 9	None Warfarin Atorvastatin Simvastatin Cetirizine Flexeril Lisinopril Losartan Amlodipine Allopurinol Maxzide Keflex Cellcept Trazodone Aspirin Trulicity Invokamet Jardiance Novolog Gabapentin Baclofen Other
Medication 10	None Warfarin Atorvastatin Simvastatin Cetirizine Flexeril Lisinopril Losartan Amlodipine Allopurinol Maxzide Keflex Cellcept Trazodone Aspirin Trulicity Invokamet Jardiance Novolog Gabapentin Baclofen Other	Medication 11	None Warfarin Atorvastatin Simvastatin Cetirizine Flexeril Lisinopril Losartan Amlodipine Allopurinol Maxzide Keflex Cellcept Trazodone Aspirin Trulicity Invokamet Jardiance Novolog Gabapentin Baclofen Other	Medication 12	None Warfarin Atorvastatin Simvastatin Cetirizine Flexeril Lisinopril Losartan Amlodipine Allopurinol Maxzide Keflex Cellcept Trazodone Aspirin Trulicity Invokamet Jardiance Novolog Gabapentin Baclofen Other

Base Curve

None Orthotrycycline Other

Over The Counter Medications

None Asprin Acetaminophen Ibuprofen Other

Vitamins

None A E C Zinc Xanten Lutein Other

Review Of Systems

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GENERAL: Fever, weight loss, weight gain, fatigue?

Negative Fatigue Fever Weight Gain Weight loss Other

EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat

None Allergies Chronic Cough Drainage Dry Throat / Mouth Earache Hard of Hearing Hoarseness Itching Nosebleeds Sinus pain Sinus Problems Sore throat Stuffiness Other

CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease

None Chest pain Difficulty breathing laying down Palpitations Shortness of breath Surgery Swelling Other

RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD

None Asthma Bronchitis COPD Emphysema Painful breathing Other

GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence

None frequent urination impotence kidney stones painful urination Other

MUSCLES, BONES, JOINTS: Athritis, Joint Pains, Head or Neck Injury

None joint pain stiffness swelling cramps arthritis Other

SKIN: growths, rashes, acne

None growths rash lumps itching dryness color change change in hair or nails Other

NEUROLOGICAL: Headaches, migraines, seizures

None dizziness fainting headache numbness, paralysis migraines seizures weakness Other

PSYCHIATRIC: Depression, Anxiety, Insomnia

None anxiety depression insomnia nervousness stress Other

ENDOCRINE: Thyroid, Diabetes

None diabetes hypothyroid hyperthoyroid excessive sweating heat or cold intolerance change in glove or shoe size Other

BLOOD/LYMPH: Anemia, cholesterol, bleeding problems

None bleeding cholestrolemia anemia brusing blood clots transfusion history Other

ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus

None sneezing swelling redness itching hives Other

GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

None Diarrhea Constipation Ulcer Acid Reflux Other

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