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:	Text Message Cell Phone Email Work Phone Home Phone Other Phone
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 AARP/Eyemed Aetna EyeMed Humana VCP Superior UFCW Veterans Choice Program-VACAA 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 AARP/Eyemed Aetna EyeMed Humana VCP Superior UFCW Veterans Choice Program-VACAA 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 AARP/Eyemed Aetna EyeMed Humana VCP Superior UFCW Veterans Choice Program-VACAA 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:

Medical History

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

Denies HTN, Heart Dx, Lung Dx, Thyroid Dx, Cancer & Inflammatory Dx - Good Health acne rosacea anemia Arthritis Asthma bronchitis Cancer Cancer breast chest cold cholesterol colitis Depression Diabetes diabetes type I diabetes type II Diagnosed As HIV+ digestive eczema emphysema epilepsy fatigue fever fibromyalgia flu Good health HBP Headaches Heart Condition heart disease herpes elsewhere herpes genital herpes ocular HX Of Drug/Alcohol Abuse hypertension Inflammatory Bowel Disease kidney problem leukemia Lupus MG myasthenia gravis MS multiple sclerosis muscular dystrophy Nursing panic disorder pregnant now psoriasis seasonal allergies Seizure Disorder shingles in the past sinus Smoking STD stroke thyroid dysfunction Ulcer urinary tract infection weight-loss Other

Injuries, Surgeries, Hospitalization

None Other

Pregnant Or Nursing:

No Yes Unsure Other

Last Eye Exam:

1 year ago 2 years ago 3 years ago 5-10 years ago over 10 years ago Other

Doctor:

Doesn't Remember Never Dr. Silver Dr. Wren Dr. Harris Lens Crafters EyeMasters Pearl Wal-Mart Other

Systemic Meds:

None Actos Acyclovir Adderall Albuterol Allegra Allopurinol Alprazolam Altace Altoprev Amaryl Ambien Amiodarone Amitriptyline Amlodipine Amlodipine Besylate Amoxicillin amphetamine salts Amrix Apixaban Apresoline Aspirin Atenolol Atorvastatin Augmentin Avastin Azithromycin Bactroban Basaglar Bentyl Benztropine Bimatoprost Boniva Brimonidine Bupropion Hydrochloride Buspar Captopril Carbamazepine Carvedilol Cataflam Cefzil Celebrex Cipro Clobetasol Clonazepam Clonidin Clopidogrel Cogentin Colchicine Coreg Coumadin Cozar Crestor Cyclobenzaprine Cymbalta Depakote Desvenlafaxine Desyrel Detrol Dextroamphetamine Diclofenac Dicyclomine Dilantin Diltiazem Diovan Docusate Dopar Drisdol Duloxetine Effexor Enbrel Escitalopram Oxalate Evista Fenofibrate Flexeril Flomax Flonase Flovent Fluoxetine Hydrochloride Fosamax Furosamide Gabapentin Genvoya Gemfibrozil Gilenya Glipizide Glucophage Glucotrol Glyburide HCTZ HumaLOG Humulin HumuLIN Hydrochlorothiazide Hydrocortisone Hydroxychloroquine Hytrin Hyzaar Ibandronate Imitrex Inbrija Isosorbide nitrate Januvia Keppra Ketoconazole Lamotrigine Lantus Larodopa Lasix Letrozole Levaquin Levemir Levitra Levocetirizine Levodopa Levothyroxine Sodium Lexipro Lioresal Lipitor Lisinopril Lithium Lorazepam Lortab Losartan Potassium Lovastatin Lunesta Luvox Lyrica Memantine Metformin Methlyprednisolone Metoprolol Succinate Mevacor Mirabegron Mirtazapine Mometasone Montelukast Sodium MS Contin Nasacort Nitrofurantoin Nitroglycerin Norvasc Novalog NovoLog Nystatin Ofloxacin Olanzapine Oleptro Olmesartan Omeprazole Ondansetron Oxycodone Pamelor Pantoprazole Pepcid Pioglitazone Plaquenil Plavix Potassium Chloride Pradaxa Pravastatin Prazosin Prednisone Premarin Prempro Prinzide Proair Progesterone Propranolol Protonix Proventil Prozac Qbrelis Quinapril Relpax Risperidone Ritalin Rivaroxaban Rosuvastatin Sertraline Sildenafil Simvastatin Singulair Sitagliptin Spironolactone Sumatriptan Synthroid Tadalafil Tamsulosin Terazosin Testosterone Tetracycline Topamax Toujeo Tramadol Trazodone Ultram Uroxatral Valacyclovir Valium Valsartan Venlafaxine Ventolin Viagra Wellbutrin Xanax Xarelto Yaz Zanaflex Zantac Zebeta Zestoretic Zestril Zetia Zocor Zoloft Zolpidem Zyban Zyloprim Other	None Actos Acyclovir Adderall Albuterol Allegra Allopurinol Alprazolam Altace Altoprev Amaryl Ambien Amiodarone Amitriptyline Amlodipine Amlodipine Besylate Amoxicillin amphetamine salts Amrix Apixaban Apresoline Aspirin Atenolol Atorvastatin Augmentin Avastin Azithromycin Bactroban Basaglar Bentyl Benztropine Bimatoprost Boniva Brimonidine Bupropion Hydrochloride Buspar Captopril Carbamazepine Carvedilol Cataflam Cefzil Celebrex Cipro Clobetasol Clonazepam Clonidin Clopidogrel Cogentin Colchicine Coreg Coumadin Cozar Crestor Cyclobenzaprine Cymbalta Depakote Desvenlafaxine Desyrel Detrol Dextroamphetamine Diclofenac Dicyclomine Dilantin Diltiazem Diovan Docusate Dopar Drisdol Duloxetine Effexor Enbrel Escitalopram Oxalate Evista Fenofibrate Flexeril Flomax Flonase Flovent Fluoxetine Hydrochloride Fosamax Furosamide Gabapentin Genvoya Gemfibrozil Gilenya Glipizide Glucophage Glucotrol Glyburide HCTZ HumaLOG Humulin HumuLIN Hydrochlorothiazide Hydrocortisone Hydroxychloroquine Hytrin Hyzaar Ibandronate Imitrex Inbrija Isosorbide nitrate Januvia Keppra Ketoconazole Lamotrigine Lantus Larodopa Lasix Letrozole Levaquin Levemir Levitra Levocetirizine Levodopa Levothyroxine Sodium Lexipro Lioresal Lipitor Lisinopril Lithium Lorazepam Lortab Losartan Potassium Lovastatin Lunesta Luvox Lyrica Memantine Metformin Methlyprednisolone Metoprolol Succinate Mevacor Mirabegron Mirtazapine Mometasone Montelukast Sodium MS Contin Nasacort Nitrofurantoin Nitroglycerin Norvasc Novalog NovoLog Nystatin Ofloxacin Olanzapine Oleptro Olmesartan Omeprazole Ondansetron Oxycodone Pamelor Pantoprazole Pepcid Pioglitazone Plaquenil Plavix Potassium Chloride Pradaxa Pravastatin Prazosin Prednisone Premarin Prempro Prinzide Proair Progesterone Propranolol Protonix Proventil Prozac Qbrelis Quinapril Relpax Risperidone Ritalin Rivaroxaban Rosuvastatin Sertraline Sildenafil Simvastatin Singulair Sitagliptin Spironolactone Sumatriptan Synthroid Tadalafil Tamsulosin Terazosin Testosterone Tetracycline Topamax Toujeo Tramadol Trazodone Ultram Uroxatral Valacyclovir Valium Valsartan Venlafaxine Ventolin Viagra Wellbutrin Xanax Xarelto Yaz Zanaflex Zantac Zebeta Zestoretic Zestril Zetia Zocor Zoloft Zolpidem Zyban Zyloprim Other	None Actos Acyclovir Adderall Albuterol Allegra Allopurinol Alprazolam Altace Altoprev Amaryl Ambien Amiodarone Amitriptyline Amlodipine Amlodipine Besylate Amoxicillin amphetamine salts Amrix Apixaban Apresoline Aspirin Atenolol Atorvastatin Augmentin Avastin Azithromycin Bactroban Basaglar Bentyl Benztropine Bimatoprost Boniva Brimonidine Bupropion Hydrochloride Buspar Captopril Carbamazepine Carvedilol Cataflam Cefzil Celebrex Cipro Clobetasol Clonazepam Clonidin Clopidogrel Cogentin Colchicine Coreg Coumadin Cozar Crestor Cyclobenzaprine Cymbalta Depakote Desvenlafaxine Desyrel Detrol Dextroamphetamine Diclofenac Dicyclomine Dilantin Diltiazem Diovan Docusate Dopar Drisdol Duloxetine Effexor Enbrel Escitalopram Oxalate Evista Fenofibrate Flexeril Flomax Flonase Flovent Fluoxetine Hydrochloride Fosamax Furosamide Gabapentin Genvoya Gemfibrozil Gilenya Glipizide Glucophage Glucotrol Glyburide HCTZ HumaLOG Humulin HumuLIN Hydrochlorothiazide Hydrocortisone Hydroxychloroquine Hytrin Hyzaar Ibandronate Imitrex Inbrija Isosorbide nitrate Januvia Keppra Ketoconazole Lamotrigine Lantus Larodopa Lasix Letrozole Levaquin Levemir Levitra Levocetirizine Levodopa Levothyroxine Sodium Lexipro Lioresal Lipitor Lisinopril Lithium Lorazepam Lortab Losartan Potassium Lovastatin Lunesta Luvox Lyrica Memantine Metformin Methlyprednisolone Metoprolol Succinate Mevacor Mirabegron Mirtazapine Mometasone Montelukast Sodium MS Contin Nasacort Nitrofurantoin Nitroglycerin Norvasc Novalog NovoLog Nystatin Ofloxacin Olanzapine Oleptro Olmesartan Omeprazole Ondansetron Oxycodone Pamelor Pantoprazole Pepcid Pioglitazone Plaquenil Plavix Potassium Chloride Pradaxa Pravastatin Prazosin Prednisone Premarin Prempro Prinzide Proair Progesterone Propranolol Protonix Proventil Prozac Qbrelis Quinapril Relpax Risperidone Ritalin Rivaroxaban Rosuvastatin Sertraline Sildenafil Simvastatin Singulair Sitagliptin Spironolactone Sumatriptan Synthroid Tadalafil Tamsulosin Terazosin Testosterone Tetracycline Topamax Toujeo Tramadol Trazodone Ultram Uroxatral Valacyclovir Valium Valsartan Venlafaxine Ventolin Viagra Wellbutrin Xanax Xarelto Yaz Zanaflex Zantac Zebeta Zestoretic Zestril Zetia Zocor Zoloft Zolpidem Zyban Zyloprim Other
None Actos Acyclovir Adderall Albuterol Allegra Allopurinol Alprazolam Altace Altoprev Amaryl Ambien Amiodarone Amitriptyline Amlodipine Amlodipine Besylate Amoxicillin amphetamine salts Amrix Apixaban Apresoline Aspirin Atenolol Atorvastatin Augmentin Avastin Azithromycin Bactroban Basaglar Bentyl Benztropine Bimatoprost Boniva Brimonidine Bupropion Hydrochloride Buspar Captopril Carbamazepine Carvedilol Cataflam Cefzil Celebrex Cipro Clobetasol Clonazepam Clonidin Clopidogrel Cogentin Colchicine Coreg Coumadin Cozar Crestor Cyclobenzaprine Cymbalta Depakote Desvenlafaxine Desyrel Detrol Dextroamphetamine Diclofenac Dicyclomine Dilantin Diltiazem Diovan Docusate Dopar Drisdol Duloxetine Effexor Enbrel Escitalopram Oxalate Evista Fenofibrate Flexeril Flomax Flonase Flovent Fluoxetine Hydrochloride Fosamax Furosamide Gabapentin Genvoya Gemfibrozil Gilenya Glipizide Glucophage Glucotrol Glyburide HCTZ HumaLOG Humulin HumuLIN Hydrochlorothiazide Hydrocortisone Hydroxychloroquine Hytrin Hyzaar Ibandronate Imitrex Inbrija Isosorbide nitrate Januvia Keppra Ketoconazole Lamotrigine Lantus Larodopa Lasix Letrozole Levaquin Levemir Levitra Levocetirizine Levodopa Levothyroxine Sodium Lexipro Lioresal Lipitor Lisinopril Lithium Lorazepam Lortab Losartan Potassium Lovastatin Lunesta Luvox Lyrica Memantine Metformin Methlyprednisolone Metoprolol Succinate Mevacor Mirabegron Mirtazapine Mometasone Montelukast Sodium MS Contin Nasacort Nitrofurantoin Nitroglycerin Norvasc Novalog NovoLog Nystatin Ofloxacin Olanzapine Oleptro Olmesartan Omeprazole Ondansetron Oxycodone Pamelor Pantoprazole Pepcid Pioglitazone Plaquenil Plavix Potassium Chloride Pradaxa Pravastatin Prazosin Prednisone Premarin Prempro Prinzide Proair Progesterone Propranolol Protonix Proventil Prozac Qbrelis Quinapril Relpax Risperidone Ritalin Rivaroxaban Rosuvastatin Sertraline Sildenafil Simvastatin Singulair Sitagliptin Spironolactone Sumatriptan Synthroid Tadalafil Tamsulosin Terazosin Testosterone Tetracycline Topamax Toujeo Tramadol Trazodone Ultram Uroxatral Valacyclovir Valium Valsartan Venlafaxine Ventolin Viagra Wellbutrin Xanax Xarelto Yaz Zanaflex Zantac Zebeta Zestoretic Zestril Zetia Zocor Zoloft Zolpidem Zyban Zyloprim Other	None Actos Acyclovir Adderall Albuterol Allegra Allopurinol Alprazolam Altace Altoprev Amaryl Ambien Amiodarone Amitriptyline Amlodipine Amlodipine Besylate Amoxicillin amphetamine salts Amrix Apixaban Apresoline Aspirin Atenolol Atorvastatin Augmentin Avastin Azithromycin Bactroban Basaglar Bentyl Benztropine Bimatoprost Boniva Brimonidine Bupropion Hydrochloride Buspar Captopril Carbamazepine Carvedilol Cataflam Cefzil Celebrex Cipro Clobetasol Clonazepam Clonidin Clopidogrel Cogentin Colchicine Coreg Coumadin Cozar Crestor Cyclobenzaprine Cymbalta Depakote Desvenlafaxine Desyrel Detrol Dextroamphetamine Diclofenac Dicyclomine Dilantin Diltiazem Diovan Docusate Dopar Drisdol Duloxetine Effexor Enbrel Escitalopram Oxalate Evista Fenofibrate Flexeril Flomax Flonase Flovent Fluoxetine Hydrochloride Fosamax Furosamide Gabapentin Genvoya Gemfibrozil Gilenya Glipizide Glucophage Glucotrol Glyburide HCTZ HumaLOG Humulin HumuLIN Hydrochlorothiazide Hydrocortisone Hydroxychloroquine Hytrin Hyzaar Ibandronate Imitrex Inbrija Isosorbide nitrate Januvia Keppra Ketoconazole Lamotrigine Lantus Larodopa Lasix Letrozole Levaquin Levemir Levitra Levocetirizine Levodopa Levothyroxine Sodium Lexipro Lioresal Lipitor Lisinopril Lithium Lorazepam Lortab Losartan Potassium Lovastatin Lunesta Luvox Lyrica Memantine Metformin Methlyprednisolone Metoprolol Succinate Mevacor Mirabegron Mirtazapine Mometasone Montelukast Sodium MS Contin Nasacort Nitrofurantoin Nitroglycerin Norvasc Novalog NovoLog Nystatin Ofloxacin Olanzapine Oleptro Olmesartan Omeprazole Ondansetron Oxycodone Pamelor Pantoprazole Pepcid Pioglitazone Plaquenil Plavix Potassium Chloride Pradaxa Pravastatin Prazosin Prednisone Premarin Prempro Prinzide Proair Progesterone Propranolol Protonix Proventil Prozac Qbrelis Quinapril Relpax Risperidone Ritalin Rivaroxaban Rosuvastatin Sertraline Sildenafil Simvastatin Singulair Sitagliptin Spironolactone Sumatriptan Synthroid Tadalafil Tamsulosin Terazosin Testosterone Tetracycline Topamax Toujeo Tramadol Trazodone Ultram Uroxatral Valacyclovir Valium Valsartan Venlafaxine Ventolin Viagra Wellbutrin Xanax Xarelto Yaz Zanaflex Zantac Zebeta Zestoretic Zestril Zetia Zocor Zoloft Zolpidem Zyban Zyloprim Other	None Actos Acyclovir Adderall Albuterol Allegra Allopurinol Alprazolam Altace Altoprev Amaryl Ambien Amiodarone Amitriptyline Amlodipine Amlodipine Besylate Amoxicillin amphetamine salts Amrix Apixaban Apresoline Aspirin Atenolol Atorvastatin Augmentin Avastin Azithromycin Bactroban Basaglar Bentyl Benztropine Bimatoprost Boniva Brimonidine Bupropion Hydrochloride Buspar Captopril Carbamazepine Carvedilol Cataflam Cefzil Celebrex Cipro Clobetasol Clonazepam Clonidin Clopidogrel Cogentin Colchicine Coreg Coumadin Cozar Crestor Cyclobenzaprine Cymbalta Depakote Desvenlafaxine Desyrel Detrol Dextroamphetamine Diclofenac Dicyclomine Dilantin Diltiazem Diovan Docusate Dopar Drisdol Duloxetine Effexor Enbrel Escitalopram Oxalate Evista Fenofibrate Flexeril Flomax Flonase Flovent Fluoxetine Hydrochloride Fosamax Furosamide Gabapentin Genvoya Gemfibrozil Gilenya Glipizide Glucophage Glucotrol Glyburide HCTZ HumaLOG Humulin HumuLIN Hydrochlorothiazide Hydrocortisone Hydroxychloroquine Hytrin Hyzaar Ibandronate Imitrex Inbrija Isosorbide nitrate Januvia Keppra Ketoconazole Lamotrigine Lantus Larodopa Lasix Letrozole Levaquin Levemir Levitra Levocetirizine Levodopa Levothyroxine Sodium Lexipro Lioresal Lipitor Lisinopril Lithium Lorazepam Lortab Losartan Potassium Lovastatin Lunesta Luvox Lyrica Memantine Metformin Methlyprednisolone Metoprolol Succinate Mevacor Mirabegron Mirtazapine Mometasone Montelukast Sodium MS Contin Nasacort Nitrofurantoin Nitroglycerin Norvasc Novalog NovoLog Nystatin Ofloxacin Olanzapine Oleptro Olmesartan Omeprazole Ondansetron Oxycodone Pamelor Pantoprazole Pepcid Pioglitazone Plaquenil Plavix Potassium Chloride Pradaxa Pravastatin Prazosin Prednisone Premarin Prempro Prinzide Proair Progesterone Propranolol Protonix Proventil Prozac Qbrelis Quinapril Relpax Risperidone Ritalin Rivaroxaban Rosuvastatin Sertraline Sildenafil Simvastatin Singulair Sitagliptin Spironolactone Sumatriptan Synthroid Tadalafil Tamsulosin Terazosin Testosterone Tetracycline Topamax Toujeo Tramadol Trazodone Ultram Uroxatral Valacyclovir Valium Valsartan Venlafaxine Ventolin Viagra Wellbutrin Xanax Xarelto Yaz Zanaflex Zantac Zebeta Zestoretic Zestril Zetia Zocor Zoloft Zolpidem Zyban Zyloprim Other

Glaucoma Meds:

None alphagan betagan betimol betoptic CAI cosopt Diamox glaucoma med unspecified iopidine lumigan neptazane ocupress ocusert optipranolol pilocar propine HS gel rescula Timoptic travatan trusopt Trusopt xalatan Other

Eye Meds:

None acular acular adsorbonac alamast alocril alomide Alphagan alrex Alrex antibiotic topical unspecified bacitracin bepreve Bepreve Bleph 10 Blephamide Blink cetapred ciloxan compliance with glaucoma meds cromlom Cromolyn NA 4% Decadron eflone elestat Elestat erythromycin flarex fluor-op FML FML forte FML UNG gentamicin Genteal inflamase forte lacrilube livostin lotemax Lotemax Lotemax maxidex Maxitrol medication compliance metimyd muro128 ung NaCl ointment neosporin no reported ocular meds not compliant with ocular medications ocufen ocuflox pataday Pataday Patanol Patanol polysporin polytrim Pred forte Pred Forte pred G. Refresh refresh ointment restasis rewetting drops steroid unspecified Systane tears natural ointment tetracycline Theratears Tobradex tobramycin tobramycin Tobrex Travatan vasocidin vexol Vigamox vira A viroptic Visine voltaren Xalatan zaditor zylet Other

Drug Allergies:

NKDA Codeine Penicillin SIlicone SCL Sulfa Other

OTC:

None Acetomenophin artificial tears Asprin Ibuprofen napcon A opcon A Visine Other

Vitamins:

None A E C Zinc Xanten Lutein icaps ocuvite Maxi vision eye promise Other

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

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

Occupation:

Manager Retired IT Retail Attorney Physician Engineer Real Estate Student Designer Construction Business Owner Other

Hobbies:

Astronomy Art Baseball Boating Basketball Cooking Crafts Dancing Diving Football Fishing Golf Gardening Horseback Riding Hunting Models Mountain Biking Needlepoint None Painting Photography Piano Reading Running Roller Blading Softball Sewing Skiing Soccer Swimming Tennis Video Games Woodworking Other

Family History: Family history is unknown/adopted

Any History Of the Following In Any Family Members (Parents, Grandparents, Siblings, Children)?

Condition	Yes	No	Relationship To Patient
Poor Vision			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather Parents Siblings Grandparents Other
Blindness			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather Parents Siblings Grandparents Other
Eye Turn (Strabismus)			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather Parents Siblings Grandparents Other
Lazy Eye (Amblyopia)			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather Parents Siblings Grandparents Other
Glaucoma			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather Parents Siblings Grandparents Other
Cataracts			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather Parents Siblings Grandparents Other
Macular Degeneration			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather Parents Siblings Grandparents Other
Retinal Detachment/Disease			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather Parents Siblings Grandparents Other

Condition	Yes	No	Relationship To Patient
Cancer			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather Parents Siblings Grandparents Other
Diabetes			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather Parents Siblings Grandparents Other
High Blood Pressure			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather Parents Siblings Grandparents Other
Heart Disease			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather Parents Siblings Grandparents Other
Thyroid Disease			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather Parents Siblings Grandparents Other
Other Inherited Disease			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather Parents Siblings Grandparents Other
If Yes What Disease?

How often do you smoke/use tobacco products?

Never Occasionally Daily Other

How often do you consume alcohol:

Never Occasionally Daily Other

Illegal drugs

Never Marijuana Other

Infectious Diseases?

None Herpes Hepatitis-A Hepatitis-B Hepatitis-C HIV Syphilis HIV Gonorrhea Other

Who referred you to our office?

If Not Referred, How Did You Hear About Silver Vision & Eyecare? Family member Insurance list Coworker Friend Primary Care Doctor Internet Drove by Other

Review Of Systems:

Do You Currently Have Any Of These Problems?

CONSTITUTIONAL: Cancer, Fever, weight loss, weight gain, fatigue	NO Negative Developmental Disorders Cancer Chronic Fatigue Syndrome Other
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry mouth/Throat	NO Allergies/Hay Fever Sinus Congestion Allergies Runny Nose Post Nasal Drip Chronic Cough Dry Throat / Mouth Seasonal allergies Sinus Problems Hay Fever Allergies/Hayfever, Sinus Congestion, Runny Nose, Post Nasal Drip, Hearing Impaired Laryngitis Sinusitis Dry Mouth Other
CARDIOVASCULAR: HTN, Heart Surgery, Vascular Disease	NO HTN Surgery Vascular Disease Stroke MitroValve Prolapse Heart Arrythmia Heart Attack Heart Disease Heart Problems Other
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD	NO Asthma Bronchitis Chronic Bronchitis Emphysema COPD Sleep Apnea Other
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence	NO frequent urination impotence yellow jaundice Surgery UTI Prostate problems Kidney problems Kidney Transplant Kidney Stones STD - Herpetic/Chlamydia Prostate Disease/Cancer Other
MUSCLES, BONES, JOINTS: Athritis, Joint Pains, Head or Neck Injury	NO arthritis Rheumatoid Arthritis Muscle Pain / Joint Pain Muscle Pain joint pain stiffness swelling cramps Broken bones Fractures Back problems Neck Problems Fibromyalgia Other
SKIN: growths, rashes, acne	NO Acne Eczema Itchy skin psoriasis Rosacea Other
NEUROLOGICAL: Headaches, migraines, seizures	NO Headaches Headaches / Migraines Tremors Paralysis Migraines Migraines with visual aura Brain Trauma concussion Brain Tumor Seizures Other
PSYCHIATRIC: Depression, Anxiety, Insomnia	NO anxiety depression insomnia Mood Disorder Bipolar Manic Depression Alzheimer's Panic Attacks Psychiatric issues Attention Deficit PTSD Autism Other
ENDORCRINE: Thyroid, Diabetes	NO Diabetes Grave's Disease hyperthoyroid hypothyroid Thyroid Problems Type 1 Diabetes Type 2 Diabetes Other
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems	NO bleeding cholestrolemia anemia Bleeding Problems Other
ALLERGIC / IMMUNOLOGIC: Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus	NO hives Sarcoid Lupus Rheumatoid Arthritis Environmental Allergies Multiple Sclerosis Sjogrens Syndrome HIV Other
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux	NO Acid Reflux Chron's Disease Chronic Constipation Chronic Diarrhea Constipation Diarrhea Heart Burn None Ulcer Irritable Bowel Syndrome IBS Other
OTHER:

REVIEW OF OCULAR SYSTEM: Injuries, Infections, Surgeries, Diseases

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