Online Patient Form

Demographics

Patient Information

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

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. Newton, W. Chris Dr. Outside, Rx Dr. Wells, Denton	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
	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:

Vision Insurance

Primary Vision Insurance

Insurance Name:	None 3M SAFETY Aetna Aetna Life Insurance Company APWU Assurant Health ASA Benefits Dept-UFCW Local 1167 Blue Cross Of California Blue Shield CALFARM Calvary Chapel Of High Desert Cemex CHAMPVA PROGRAM Choctaw Nation Health Services CIGNA Cigna Global Health Benefits Cigna Healthcare Compbenefits Vision Care Delta Health Systems EBAM Corporation EyeMed Vision Care GEHA-ASA Health Net Commercial Claims Humana Humana Vision Care Plan IEHP LLUAHSC Medi-Cal Medical Eye Services Medical Eye Services COB Medicare Mutual Of Omaha Life Ins Co NALC Health Benefit Plan Nat'l Auto Sprinkler Ind Wel Fnd Noridian Administrative Services NVISION O.E. Health & Welfare Fund Pacific Eye Institute Principal Life Insurance Co Railroad Medicare San Diego & Imperial FBC So Cal Pipe Trades H&W Fund Spring Valley Lake Lions Club The Mail Handlers Benefit Plan Tricare UMR United Health Care Vision Service 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 Vision Insurance

Insurance Name:	None 3M SAFETY Aetna Aetna Life Insurance Company APWU Assurant Health ASA Benefits Dept-UFCW Local 1167 Blue Cross Of California Blue Shield CALFARM Calvary Chapel Of High Desert Cemex CHAMPVA PROGRAM Choctaw Nation Health Services CIGNA Cigna Global Health Benefits Cigna Healthcare Compbenefits Vision Care Delta Health Systems EBAM Corporation EyeMed Vision Care GEHA-ASA Health Net Commercial Claims Humana Humana Vision Care Plan IEHP LLUAHSC Medi-Cal Medical Eye Services Medical Eye Services COB Medicare Mutual Of Omaha Life Ins Co NALC Health Benefit Plan Nat'l Auto Sprinkler Ind Wel Fnd Noridian Administrative Services NVISION O.E. Health & Welfare Fund Pacific Eye Institute Principal Life Insurance Co Railroad Medicare San Diego & Imperial FBC So Cal Pipe Trades H&W Fund Spring Valley Lake Lions Club The Mail Handlers Benefit Plan Tricare UMR United Health Care Vision Service 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:

Medical Insurance

Primary Medical Insurance

Insurance Name:	None 3M SAFETY Aetna Aetna Life Insurance Company APWU Assurant Health ASA Benefits Dept-UFCW Local 1167 Blue Cross Of California Blue Shield CALFARM Calvary Chapel Of High Desert Cemex CHAMPVA PROGRAM Choctaw Nation Health Services CIGNA Cigna Global Health Benefits Cigna Healthcare Compbenefits Vision Care Delta Health Systems EBAM Corporation EyeMed Vision Care GEHA-ASA Health Net Commercial Claims Humana Humana Vision Care Plan IEHP LLUAHSC Medi-Cal Medical Eye Services Medical Eye Services COB Medicare Mutual Of Omaha Life Ins Co NALC Health Benefit Plan Nat'l Auto Sprinkler Ind Wel Fnd Noridian Administrative Services NVISION O.E. Health & Welfare Fund Pacific Eye Institute Principal Life Insurance Co Railroad Medicare San Diego & Imperial FBC So Cal Pipe Trades H&W Fund Spring Valley Lake Lions Club The Mail Handlers Benefit Plan Tricare UMR United Health Care Vision Service 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 Name:	None 3M SAFETY Aetna Aetna Life Insurance Company APWU Assurant Health ASA Benefits Dept-UFCW Local 1167 Blue Cross Of California Blue Shield CALFARM Calvary Chapel Of High Desert Cemex CHAMPVA PROGRAM Choctaw Nation Health Services CIGNA Cigna Global Health Benefits Cigna Healthcare Compbenefits Vision Care Delta Health Systems EBAM Corporation EyeMed Vision Care GEHA-ASA Health Net Commercial Claims Humana Humana Vision Care Plan IEHP LLUAHSC Medi-Cal Medical Eye Services Medical Eye Services COB Medicare Mutual Of Omaha Life Ins Co NALC Health Benefit Plan Nat'l Auto Sprinkler Ind Wel Fnd Noridian Administrative Services NVISION O.E. Health & Welfare Fund Pacific Eye Institute Principal Life Insurance Co Railroad Medicare San Diego & Imperial FBC So Cal Pipe Trades H&W Fund Spring Valley Lake Lions Club The Mail Handlers Benefit Plan Tricare UMR United Health Care Vision Service 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:

Medical History

Patient Medical History

Eye History			Medical History
Glaucoma:	Yes	No	Diabetes:	Yes	No	Year Diagnosed:		A1c:
Mac Degen:	Yes	No	High Blood Pressure:	Yes	No
Retinal Disease:	Yes	No	Thyroid Disease:	Yes	No
Cataracts:	Yes	No	Heart Disease:	Yes	No
Blindness:	Yes	No	Cancer:	Yes	No
Crossed Eyes:	Yes	No	Arthritis:	Yes	No
Lazy Eye:	Yes	No	Asthma:	Yes	No
Color Blindness:	Yes	No	Emphysema:	Yes	No
Double Vision:	Yes	No	Headaches/Migraines:	Yes	No
Serious Eye Infection:	Yes	No	Cholesterol:	Yes	No
Flashes/Floaters:	Yes	No

Other Patient Ocular Conditions:	Other Patient Medical Conditions:

Eye Surgeries:

Eye Injuries:

Medications:	Allergies:

Primary Care Physician:
Referring Physician:		Phone Number:

Family Medical History

Family History Unknown

Family Eye History

	None	Mom	Dad	Sibling	Paternal   Grandmother	Paternal   Grandfather	Maternal   Grandmother	Maternal   Grandfather
Glaucoma:
Macular Degen:
Retinal Disease:
Cataracts:
Lazy/Cross Eye:
Blindness:

Other Family Ocular Conditions:

Family Medical History

	None	Mom	Dad	Sibling	Paternal   Grandmother	Paternal   Grandfather	Maternal   Grandmother	Maternal   Grandfather
Diabetes:
High Blood Pressure:
Thyroid Disease:
Heart Disease:
Cancer:

Other Family Medical Conditions:

Review of Systems

General:	none fatigue fever other unexplained weight change Other	Ears/Nose/Throat:	none chronic cough dry mouth runny nose sinus congestion Other
Eyes:	none Other	Musculoskeletal:	none muscle/joint pain rheumatoid arthritis swollen joints Other
Immune:	none allergies hay fever Other	Cardiovascular:	none chest pain circulatory or vascular disease heart problems high blood pressure high cholesterol stroke Other
Skin:	none excessive dryness itching rashes Other	Gastrointestinal:	none Crohn's Disease Inflammatory Bowel Disease Other
Psychiatric:	none ADHD anxiety depression special needs Other	Genitourinary:	none genitals kidney or bladder problems Other
Endocrine:	none diabetes neck pain other glands thyroid Other	Blood/Lymph:	none anemia bleeding problems blood disorders Other
Respiratory:	none asthma chronic bronchitis coughing emphysema shortness of breath wheezing Other	Nervous System:	none dizziness headaches motion sickness multiple sclerosis numbness paralysis seizures weakness Other

Social History

Race:

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

Ethnicity:

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

Preferred Language

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 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

Alcohol Use:

no occasionally Other

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