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
Misc/Guardian		Drivers License #

Is the Billing Address Different?

Billing Information

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

Copy Address From Above
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 BCBS BLOCK VISION CIGNA MEDICAL CIGNA VISION DAVIS VISION EYEMED HUMANA HUMANA VCP MEDICARE MOLINA New Insurance OPTICARE OTHER SPECTERA SUPERIOR VISION TRADITIONAL MEDICAID TRICARE PRIME UHC UMR 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 BCBS BLOCK VISION CIGNA MEDICAL CIGNA VISION DAVIS VISION EYEMED HUMANA HUMANA VCP MEDICARE MOLINA New Insurance OPTICARE OTHER SPECTERA SUPERIOR VISION TRADITIONAL MEDICAID TRICARE PRIME UHC UMR 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 BCBS BLOCK VISION CIGNA MEDICAL CIGNA VISION DAVIS VISION EYEMED HUMANA HUMANA VCP MEDICARE MOLINA New Insurance OPTICARE OTHER SPECTERA SUPERIOR VISION TRADITIONAL MEDICAID TRICARE PRIME UHC UMR 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:

Chief Complaint

CHIEF COMPLAINT

Secondary Complaints:

PATIENT OCULAR HISTORY: Injuries, Infections, Surgeries, Diseases

NONE AMBLYOPIA CATARACTS EYE INJURIES FLASHES OF LIGHT FLOATERS GLAUCOMA INJECTIONS FOR AMD OU IOL RD REPAIR RETINAL DISORDER STRABISMUS Other

Last Eye Exam:
1 YEAR 2 YEARS 3 YEARS 4 YEARS 5 YEARS 6 YEARS 7 YEARS 8 YEARS 9 YEARS 10 YEARS 10+ YEARS Other	Doctor:	DOESN'T REMEMBER NO EYE DOCTOR BEFORE EYEMASTER DR LENSCRAFTERS DR SEARS DR TARGET DR TSO DR VISION SOURCE DR WALMART DR Other	Eye Meds:	NONE AREDS FOR GLAUCOMA FOR DRY EYE Other

Interested in contacts?

NO YES Other

Worn contacts previously?

NO YES Other

Type of CLs worn in past:

DISPOSABLE TORIC COLORED RGP ACUVUE OASYS AIR OPTIX AIR OPTIX ASTIG Other

Interested in Lasik?

NO YES Other

FAMILY OCULAR HISTORY

Medical History

PATIENT MEDICAL HISTORY: HAs, Arthritis, Asthma, Diabetes, HBP, Heart, Infl. Bowel Dz, Seizures, Thyroid

See scanned document GOOD HEALTH ALZHEIMER'S ARTHRITIS ASTHMA DIABETES DIAGNOSED HIV+ HBP HEADACHES HEART CONDITION HX OF DRUG/ALCOHOL ABUSE INFLAMMATORY BOWEL DISEASE NURSING SEIZURE DISORDER THYROID DISEASE Other

Injuries, Surgeries, Hospitalization

Pregnant Or Nursing:	NO YES UNSURE Other
Primary Care Physician:	DOESN'T REMEMBER DOESN'T HAVE ONE NONE Other	Last Visit:	1 week 1 month 3 months 6 months 1 year 2 years Other

Systemic Meds:

NONE HCTZ GLYBURIDE HYDROCORTISONE GLUCOPHAGE METFORMIN METHYLPREDNISOLONE PREDNISONE ACTOS AMARYL HUMULIN NOVALOG PREMPRO PREMARIN SYNTHROID AMIODARONE ATENOLOL CAPTOPRIL CLONIDIN FUROSAMIDE LASIX ZESTRIL ALTASE COZAR CRESTOR DIOVAN LIPITOR ALBUTEROL ALLEGRA FLONASE NASACORT SINGULAIR PROVENTIL PEPCID ZANTAC PROTONIX DETROL FLOMAX XANAX WELLBUTRIN VALIUM PROZAC RITALIN ADDERALL EFFEXOR ZOLOFT DICLOFENAC LORTAB OXYCODONE CELEBREX CARBAMAZEPINE TOPAMAX DILANTIN COUMADIN PLAVIX BACTROBAN CIPRO ACYCLOVIR CEFZIL AMOXYCILLIN AUGMENTIN TETRACYCLINE PLAQUENIL LEVAQUIN Other

Drug Allergies:

NKDA CODEINE PENICILLIN SULFA Other

FAMILY MEDICAL HISTORY: Diabetes, HBP, Heart Dz, Cancer, Athritis, Lupus, Kidney, Thyroid, Other

NONE ADOPTED ARTHRITIS CANCER CARDIOVASCULAR DISEASE DIABETES HBP KIDNEY DISEASE LUPUS THYROID Other

Social History

Tobacco:	No Yes Other
Alcohol:	No Yes Occasionally Socially Other
Illegal Drugs:	No Yes Other

Hobbies:

Review Of Systems

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 HIGH BP VASCULAR DISEASE SURGERY Other
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD	NONE ASTHMA BRONCHITIS COPD EMPHYSEMA Other
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence	NONE FREQUENT URINATION IMPOTENCE PAINFUL URINATION YELLOW JAUNDICE Other
MUSCLES, BONES, JOINTS: Athritis, Joint Pains, Head or Neck Injury	NONE ARTHRITIS CRAMPS JOINT PAIN STIFFNESS SWELLING Other
SKIN: growths, rashes, acne	NONE GROWTHS PIMPLES RASH WARTS Other
NEUROLOGICAL: Headaches, migraines, seizures	NONE PARALYSIS TREMORS Other
PSYCHIATRIC: Depression, Anxiety, Insomnia	NONE ANXIETY DEPRESSION INSOMNIA Other
ENDORCRINE: Thyroid, Diabetes	NONE DIABETES HYPERTHYROID HYPOTHYROID Other
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems	NONE ANEMIA BLEEDING CHOLESTEROLEMIA Other
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus	NONE HIVES ITCHING LUPUS REDNESS SNEEZING SWELLING Other
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux	None Diarrhea Constipation Ulcer Acid Reflux Other

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