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Demographics

Patient Information

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

Address:
City:		State/ZipCode	AK AZ AR CA 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 TX UT VT VI VA WA WV WI WY AL

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
Eye Doctor	Dr. Shane Claborn Dr. Laura England Dr. Brandon Ross Dr. Howard Ross Dr. Larry Silkey Dr. Timothy Snider Dr. Chris Swanson	Misc/Guardian

Billing Information

Is The Billing Address the Same?

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

Address

City	State	ZipCode
	AK AZ AR CA 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 TX UT VT VI VA WA WV WI WY AL

Home Phone:
Work Phone:

Primary Medical Insurance

Insurance Information

Insurance Name:	None No Name 3M Safety/Goodyear AARP Aetna ASI Insurance Co Benefit Management Administrators, INC Benefit Management Services, INC Blue Cross Blue Shield Blue Cross MCA Cigna Clearsight Center Concorde Coventry Health and Life CVP--Corporate Vision Plan Delta Vision Dept of Rehabilitation Services DMERC Equitable Life and Casualty Insurance Co Essilor labs/AEP safety program EYEMED DISCOUNT ONLY PLANS EyeMed Vision Care GEHA/UnitedHealth Integrated Services Global Health Golden Rule Insurance Co. Healthcare Highways Healthchoice of OK HealthSCOPE Benefits Humana Insurance Kempton Group Mail Handlers Medicaid OK Medicare Part B Meritain Health Mutual Assurance Admin., Inc Mutual of Omaha NALC Health Benefit Plan nJoy Vision Physicians Mutual Insurance Preferred Community Choice Primary Vision Care Service Principal Finacial Group Puritan Life Insurance Co. Reserve National Insurance Sentinel Security Life Ins State Farm Health Insurance Test Tricare East Region UMR United Healthcare Universal Fidelity Life Insurance Co VA Champva Vision Care Direct Vision Service Plan Vision USA Web-TPA WPS Tricare for Life
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:

Primary Vision Insurance

Insurance Information

Insurance Name:	None No Name 3M Safety/Goodyear AARP Aetna ASI Insurance Co Benefit Management Administrators, INC Benefit Management Services, INC Blue Cross Blue Shield Blue Cross MCA Cigna Clearsight Center Concorde Coventry Health and Life CVP--Corporate Vision Plan Delta Vision Dept of Rehabilitation Services DMERC Equitable Life and Casualty Insurance Co Essilor labs/AEP safety program EYEMED DISCOUNT ONLY PLANS EyeMed Vision Care GEHA/UnitedHealth Integrated Services Global Health Golden Rule Insurance Co. Healthcare Highways Healthchoice of OK HealthSCOPE Benefits Humana Insurance Kempton Group Mail Handlers Medicaid OK Medicare Part B Meritain Health Mutual Assurance Admin., Inc Mutual of Omaha NALC Health Benefit Plan nJoy Vision Physicians Mutual Insurance Preferred Community Choice Primary Vision Care Service Principal Finacial Group Puritan Life Insurance Co. Reserve National Insurance Sentinel Security Life Ins State Farm Health Insurance Test Tricare East Region UMR United Healthcare Universal Fidelity Life Insurance Co VA Champva Vision Care Direct Vision Service Plan Vision USA Web-TPA WPS Tricare for Life
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:

Eye History

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History

#1 SYMPTOM	Blurry computer vision Blurry vision at intermediate range Blurry vision at night Blurry vision with night time driving Burning/Stinging Cloudiness in vision Curtain or vail over vision Cycloplegic refraction exam Decreased vision at distance Decreased vision at distance and near Decreased vision at near Dilated retinal exam with fundus photos and eye steering for Dilated retinal exam with fundus photos for Discharge/Mattering Distorted Vision Double Vision Dry Dry eye testing and evaluation Eye Turns Eyelash Loss Eyelid Bump Eyelid Crusting Eyelid Drooping Eyelid Swelling Eyelid Twitch Eye(s) Bulging Eye(s) Jumping Eyes feel tired Eye strain Failed vision screening Film over vision Flashes of Light Floaters Focusing problems while reading Follow up appointment for Foreign Body Sensation Glare Glasses re-check Glaucoma follow up Glaucoma follow up with gonioscopy, fundus photos, and IOP check Halos around Lights Having to sit close to see TV Hazy vision Headache Itchy Eye(s) Light Sensitivity Night Blindness No eye health complaints No vision changes noticed Pain Red eye examination Red Eye(s) Refraction only Special testing review with doctor "Spots" in front of Eyes Sandy/Gritty Feeling Visual aura Watery/Tearing with contact lenses on without contact lenses on with Glasses on without Glasses on Other
Associated Symptoms	HA Red Pus Mucous Tears Dry Itch Photophobia Flashes Floaters Pt denies flashes, floaters, shadows/curtains Other
Secondary Complaints	Pt. states no dry or itchy eyes Blur at distance and near Blurred distance vision Blurred near vision w/glasses on w/out glasses Update eyeglass Rx Update CL Rx Problems with current CL Failed School Screening Failed DPS exam Work Requirement Interested in Multifocal SCLs Interested in Colored SCLs Interested in EW contacts Would like to try contacts None Dry Itchy Watery Red Floater(s) OD OS OU mild moderate severe daily weekly seasonal Other
Habitual RX	None SV glasses Readers Only PALs FT BF TF Soft Contact lenses Readers over SCL Mutifocal SCL Mono Vision SCL RGPs Other
Are you interesed in glasses, contacts, or both?	Other Glasses Contacts Both
Do you have back up glasses?	Other Yes No
Do you have computer glasses?	Other Yes No
Do you have sunglasses?	Other Yes No Transitions Clip ons OTCs Polarized

Interested in Laser?

Contact Lens History	Not interested in Contacts Disposable Colored Mono vision RGP Never worn Tried briefly yrs ago/unsuccessful Wore for years/dry eye problems Can wear any brand wore CL for yrs/discont due to problems Sensitive eyes Could not wear the last lenses Rxd KERATOCONUS SCL MULTIFOCAL GP MULTIFOCAL Other	Brand	TruEyes One Day Moist Oasys Oasys for Astigmatism Oasys for Prebyopia Focus Dailies Aqua + Air Optix Air Optix for Astig Air Optix Multifocal Freshlook Freshlook Toric Biofinity Biofinity Toric Biofinity Multifocal Proclear Proclear Toric Proclear Toric XR Proclear Toric MF Proclear Multifocal Encore Premium Vertex Toric Vertex Toric XR Freq 55 Toric Freq 55 Multifocal Soflens 66 Toric Soflens Multifocal Purevision 2 HD Purevision 2 for Astigmatism AV One Day Moist Acuvue Oasys FRESHLOOK UF 55 Toric UF 55 Aspheric Cooper Ciba B&L Vistakon Unsure Other	Wear Time	8 - 10 Hours Full waking hours Sleep wear Occasional EW Extended Wear EW 1-2 x per month EW 1-2 x per week EW 3+ days per week EW 1 week EW 2 weeks EW continuous 30 days Only on Weekends Only to work Recreational sports only Other
Replacement Schedule	Monthly Daily Disposable 2 Week Quarterly Yearly "wears for months" "wears until they bother..." wearing original samples Other	Cleaner	Optifree Proline Aquify Clear Care Complete Renu Boston Aosept Equate Store Brand "The Cheapest" Pure Moist Biotrue Other	Age of Current Contacts	> 1 2 3 4 5 6 day(s) week(s) month(s) year(s) Other
Reason(s) For Not Trying or Wearing Contacts	Dryness Uncomfortable Inconvenient A previous doctor said I couldn't Other	Unsussessful Contacts	TruEyes One Day Moist Oasys Oasys for Astigmatism Oasys for Prebyopia Focus Dailies Aqua + Air Optix Air Optix for Astig Air Optix Multifocal Freshlook Freshlook Toric Biofinity Biofinity Toric Biofinity Multifocal Proclear Proclear Toric Proclear Toric XR Proclear Toric MF Proclear Multifocal Encore Premium Vertex Toric Vertex Toric XR Freq 55 Toric Freq 55 Multifocal Soflens 66 Toric Soflens Multifocal Purevision 2 HD Purevision 2 for Astigmatism AV One Day Moist Acuvue Oasys FRESHLOOK UF 55 Toric UF 55 Aspheric Other	Last Time Wore Contacts	> 1 2 3 4 5 6 day(s) week(s) month(s) year(s) Other
Anything About Previous Contacts That You Wish Could Be Better	Yes No More Comfortable Better Vision Less Dry Able To Sleep In Cheaper Last Longer Other

PATIENT OCULAR HISTORY (ex. Injuries, Infections, Surgeries, Diseases, etc)

None Itching Burning, Stinging Eye Surgery Flashes Of Light Floaters was told "might have glaucoma" Glaucoma Cataracts Cataract surgery Strabismus/no surgery Strabismus surgery "Lazy eye" (Amblyopia) Corneal ulcer Recurrent infections LASIK RK PRK Macula degeneration Diabetic retinopathy/laser trmt Diabetic retinopathy/monitering Recurrent hordeolum foreign body history Eye injury w/ vision loss Eye injury w/o vision loss Retinal problem/unknown dx keratoconus Corneal dystrophy Other

Length of Time

Not sure 1 2 3 4 5 6 >10 Week(s) Month(s) Year(s) Other

Eye Meds:

Last Eye Exam:	Other 1 year 2 years 3 years never years ago cannot remember
Doctor:	Other Doesn't Remember Dr. Brett Wagner Dr. Kamran Massoumi Dr. Jean Hausheer Dr. John Barnes Dr. Shane Claborn Dr. Walt Dunlap Dr. Kristina Flint Dr. Laura England Dr. Bob Head Dr. Kyle Head Dr. Russ Hopkins Dr. Monique Leong Dr. Dean Nolan Dr. Brandon Ross Dr. Howard Ross Dr. Larry Silkey Dr. Timothy Snider Dr. Rick Swales Dr. Chris Swanson Dr. Ann Warn Dr. J.J. Young

Family Ocular History (e.g. glaucoma, retinal detachment, macular degeneration, crossed/lazy eyes, blindness, cataracts, other eye diseases, etc.):

Medical History

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Demographic information

Preferred Language:	Other English Spanish French Patient Declined to Specify Abkhazian Afar Afrikaans Akan Albanian Amharic Arabic Aragonese Armenian Assamese Avaric Avestan Aymara Azerbaijani Bambara Bashkir Basque Belarusian Bengali Bihari languages Bislama Bokm?l, Norwegian), Norwegian Bokm?l Bosnian Breton Bulgarian Burmese Catalan; Valencian Central Khmer Chamorro Chechen Chichewa; Chewa; Nyanja Chinese Church Slavic; Old Slavonic; Church Slavonic; Old Bulgarian; Old Church Slavonic Chuvash Cornish Corsican Cree Croatian Czech Danish Divehi; Dhivehi; Maldivian Dutch; Flemish Dzongkha Esperanto Estonian Ewe Faroese Fijian Finnish Fulah Gaelic; Scottish Gaelic Galician Ganda Georgian German Greek, Modern (1453-) Guarani Gujarati Haitian; Haitian Creole Hausa Hebrew Herero Hindi Hiri Motu Hungarian Icelandic Ido Igbo Indonesian Interlingua (International Auxiliary Language Association) Interlingue; Occidental Inuktitut Inupiaq Irish Italian Japanese Javanese Kalaallisut; Greenlandic Kannada Kanuri Kashmiri Kazakh Kikuyu; Gikuyu Kinyarwanda Kirghiz; Kyrgyz Komi Kongo Korean Kuanyama; Kwanyama Kurdish Lao Latin Latvian Limburgan; Limburger; Limburgish Lingala Lithuanian Luba-Katanga Luxembourgish; Letzeburgesch Macedonian Malagasy Malay Malay Malayalam Maltese Manx Maori Maori Marathi Marshallese Mongolian Nauru Navajo; Navaho Ndebele, North; North Ndebele Ndebele, South; South Ndebele Ndonga Nepali Northern Sami Norwegian Norwegian Nynorsk; Nynorsk, Norwegian Occitan (post 1500) Ojibwa Oriya Oromo Ossetian; Ossetic Pali Panjabi; Punjabi Persian Polish Portuguese Pushto; Pashto Quechua Romanian; Moldavian), Moldovan Romansh Rundi Russian Samoan Sango Sanskrit Sardinian Serbian Shona Sichuan Yi; Nuosu Sindhi Sinhala; Sinhalese Slovak Slovenian Somali Sotho, Southern Sundanese Swahili Swati Swedish Tagalog Tahitian Tajik Tamil Tatar Telugu Thai Tibetan Tigrinya Tonga (Tonga Islands) Tsonga Tswana Turkish Turkmen Twi Uighur; Uyghur Ukrainian Urdu Uzbek Venda Vietnamese Volap?k Walloon Welsh Western Frisian Wolof Xhosa Yiddish Yoruba Zhuang; Chuang Zulu
Race:	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Patient Declined to Specify
Ethnicity:	Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify

Height: Ft. In.       Weight: Lbs.

PATIENT MEDICAL HISTORY (ex. HAs, Arthritis, Asthma, Diabetes, HBP, Heart, Infl. Bowel Dz, Seizures, Thyroid, etc)

Injuries, Surgeries, Hospitalization

None past pregnancy car accident surgery Other

Diabetes Information

Diabetes:	Other Yes No Unsure Type I Type II	Duration:		Physician:
HA1c		When	1 2 3 4 5 6 >10 day(s) ago week(s) ago month(s) ago year(s) ago Other	LBS	Patient does not know. Other
When	this morning. 1 2 3 4 5 6 >10 day(s) ago week(s) ago month(s) ago year(s) ago Other	Tx	Insulin Oral Hypoglycemic Diet Control Excercise None Other
Last OV	1 week 1 month 3 months 6 months 1 year 2 years >2 years Other	Next OV	1 week 1 month 3 months 6 months 1 year 2 years >2 years Other

Miscelaneous Information

Headaches:	Other No Yes	Location	Behind the eyes Brow Top of Head Sinus Side of head Back of head Upper Neck Other	Triggers	When reading At School Not Sure on the computer Other	Relief	OTC Medication Rx Medication Nothing Sleeping cessation of reading dark room quiet place putting on glasses taking glasses off Other
Primary Care Physician:	Other None Doesn't Have One Doesn't Remember Aiku Atkinson Bellino Birdwell Brittingham Caballero Campbell Carroll Cibes-Silva Coleman Constance Dave Duguid duToit Evans Gordon Horton Ismail Jones Kadivar Legako Lewis Love Malling Maury Nokes Paszkowiak Ramos Sanner Shea Smith Solitario Stillick Vassileva Velury	Last OV	1 week 1 month 3 months 6 months 1 year 2 years >2 years Other	Reason	Annual Check up Illness well check Follow up on physical Other

Pregnant Or Nursing

Other No Yes Unsure

Birth Control

Tetanus Yr

1 year ago Several years ago Don't remember Other

FAMILY MEDICAL HISTORY: (ex. Diabetes, HBP, Heart Dz, Cancer, Athritis, Lupus, Kidney, Thyroid, etc):

Unknown family history

Social History

Occupation	Computer Industry Construction Disabled Driver Educator/Teacher Farmer/Rancher Healthcare Laborer Law Enforcement/Fireman Lawyer Ministry Not currently working Professional/Financial Professional/Medical Restaurant Retail Retired Self-Employed Student Other	Employer	Arvest Bar S Casino CCMH Dillards Ft. Sill Goodyear LPS Retired Self Wal-Mart Target Other	Lifestyle Catagories	Fitness - Aerobic Fitness - Water sports Fitness - Snow sports Fitness - Ball sports Fitness - Matial arts Fitness - Extreme sports Sportsman Craft/hobbies Computer Music Outdoors leisure Indoors leisure Home/car repair 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

If selected yes to any of the below, please also indicate what type.

Tobacco:	Other No Yes	Type:	Other None Cigarettes Chewing Tobacco	How Long:
Alcohol:	Other No Yes Occasionally Socially	Type:	Other None Beer Wine Hard Liquor
Recreational Drugs:	Other No Yes	Type:
STDs:	Other None Gonorrhea Syphilis Hepatitis HIV TB

Review of Systems

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

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ACCEPTANCE OF FINANCIAL RESPONSIBILITY


I certify that I am financially responsible for any charges incurred, regardless of whether or not I (or my dependent) have insurance coverage. I authorize the doctor to release all information necessary to secure payment of benefits from my insurance company/companies listed on the back of this form. I understand and agree it is my responsibility and not the responsibility of the doctor or the staff to know if my insurance will pay for any medical or vision service I receive, if I have a deductible to meet, any co-payments, co-insurance due for services rendered, out-of-network benefits, or any type of benefit information for the medical or vision service I receive.

I Authorize the use of this signature on all insurance submissions and/or my acceptance of financial responsibility for services rendered without having insurance.

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PRIVACY POLICY / HIPAA


I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: conduct, plan, and direct my treatment and follow-up among multiple healthcare providers who may be involved in the treatment both directly and indirectly, obtain payment from third party payers, conduct normal healthcare operations such as quality assessments and physicians certification. I have received/been offered, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information.

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