Online Patient Form
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Demographics
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:
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. Mock, Virginia
Misc/Guardian
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
Insurance Name:
None
Advantica
Aetna
Always Care
Avesis
BCBS
Davis Vision
Eyemed
Groupon
Humana
Humana VCP
Liberty Healthshare/MedCost Solutions LLC
Medicare
MES Vision
Multiplan
NVA
PHCS
PHCS Savility
Prime Health Services Inc.
Private Pay
Spectera Eyecare Networks
Superior Vision
TML
Tricare
Tricare for Life
UHC ALL SAVERS
UMR(GEHA)
United Healthcare
VBA (Vision Benefits of America)
Vision Care Advantage
VSP In-Network
VSP Out-Of-Network
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
Insurance Name:
None
Advantica
Aetna
Always Care
Avesis
BCBS
Davis Vision
Eyemed
Groupon
Humana
Humana VCP
Liberty Healthshare/MedCost Solutions LLC
Medicare
MES Vision
Multiplan
NVA
PHCS
PHCS Savility
Prime Health Services Inc.
Private Pay
Spectera Eyecare Networks
Superior Vision
TML
Tricare
Tricare for Life
UHC ALL SAVERS
UMR(GEHA)
United Healthcare
VBA (Vision Benefits of America)
Vision Care Advantage
VSP In-Network
VSP Out-Of-Network
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
Insurance Name:
None
Advantica
Aetna
Always Care
Avesis
BCBS
Davis Vision
Eyemed
Groupon
Humana
Humana VCP
Liberty Healthshare/MedCost Solutions LLC
Medicare
MES Vision
Multiplan
NVA
PHCS
PHCS Savility
Prime Health Services Inc.
Private Pay
Spectera Eyecare Networks
Superior Vision
TML
Tricare
Tricare for Life
UHC ALL SAVERS
UMR(GEHA)
United Healthcare
VBA (Vision Benefits of America)
Vision Care Advantage
VSP In-Network
VSP Out-Of-Network
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
Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!
Eye History
Reason for Visit:
blurrred vision
distance vision blurry
near vision blurry
vision blurry distance and near
wants to be fitted for contacts
needs new glasses
red eye
pain in eye
loss of vision
injury to eye
itching
burning
stinging
dry eyes
Diabetic eye exam
annual doctor directed diabetic eye exam
broken glasses
Lost RX
failed screening at school
failed screening at pediatrician's office
Physician directed eye exam
Complete eye exam to rule out problems
needs more contacts
Other
Secondary Reasons:
Do you have a history of any of these eye conditions?
None
Itching
Burning, Stinging
Red
Floaters
Flashes Of Light
Eye Injuries
Eye Surgery
Amblyopia
Strabismus
Cataracts
Glaucoma
Retinal Disorders
Other
Do you use any eye medications?:
None
Cromolyn NA 4%
Visine
Patanol
Xalatan
Travatan
rewetting drops
Elestat
Vigamox
Alphagan
Refresh
Theratears
Genteal
Pred Forte
Lotemax
Alrex
Systane
Blink
Other
Last Eye Exam:
1 year
2 years
3 years
Other
By Doctor:
Primary Vision Correction:
None
Glasses-Full Time
Glasses-Readers Only
Contacts - Soft
Over the counter readers
Other
Do you have backup glasses?
No
Yes
Other
Do you want new glasses?
Yes
No
Other
Contact Lens Wearers
Type of contacts worn in past:
None
Disposable
Conventional
Colored
RGP
PMMA
Cobalt Study Lens
Soft
Other
How long do you wear your contacts?:
>2 hours today
All day
Occ. Overnight
Extended
8 hours
10 hours
12 hours
Overnight
Other
What contact solution do you use?:
None
PureMoist
Optifree
Clear Care
Boston
Renu
Biotrue
Aquify
Other
How often do you change out your contacts?:
daily
2 weeks
monthly
weekly
yearly
Other
Review of Symptoms
General Symptoms:
None
Negative
Other
Skin:
None
pimples, warts
growths
rash
Other
Ear, Nose, and Throat:
None
Allergies
Sinus Problems
Chronic Cough
Dry Throat / Mouth
Hard of Hearing
Other
Neurological:
None
numbness, paralysis
headache
seizures
migraines
Other
Cardiovascular:
None
Vascular Disease
HBP
Heart Surgery
Other
Psychiatric:
None
anxiety
depression
insomnia
Other
Respiratory:
None
Asthma
Bronchitis
Emphysema
COPD
Other
Endocrine:
None
diabetes
hypothyroid
hyperthoyroid
Other
Genital, Kidney, Bladder:
None
painful urination
frequent urination
impotence
yellow jaundice
Other
Blood/Lymph:
None
bleeding
cholestrolemia
anemia
Other
Muscles, Bones, Joints:
None
joint pain
stiffness
swelling
cramps
arthritis
Other
Allergies:
None
sneezing
swelling
redness
itching
hives
lupus
Other
Gastrointestinal:
None
Diarrhea
Constipation
Ulcer
Acid Reflux
Other
Medications, Allergies, and Other History
Medications:
Drug Allergies:
Vitamins:
Over the Counter Meds:
Primary Care Physician:
Last Visit:
1 week
1 month
3 months
6 months
1 year
2 years
greater than 3 years
Other
Reason:
Check up
Annual
Specific
Other
Pregnant/Nursing:
No
Yes
Unsure
Other
Recent Tetanus Shot:
Yes
No
Other
Injuries/Surgeries/Hospitalization:
Family Medical History
None
Adopted
Diabetes
HBP
Cancer
Cardiovascular Disease
Athritis
Kidney Disease
Lupus
Thyroid
Other
None
Adopted
Diabetes
HBP
Cancer
Cardiovascular Disease
Athritis
Kidney Disease
Lupus
Thyroid
Other
None
Adopted
Diabetes
HBP
Cancer
Cardiovascular Disease
Athritis
Kidney Disease
Lupus
Thyroid
Other
None
Adopted
Diabetes
HBP
Cancer
Cardiovascular Disease
Athritis
Kidney Disease
Lupus
Thyroid
Other
None
Adopted
Diabetes
HBP
Cancer
Cardiovascular Disease
Athritis
Kidney Disease
Lupus
Thyroid
Other
None
Adopted
Diabetes
HBP
Cancer
Cardiovascular Disease
Athritis
Kidney Disease
Lupus
Thyroid
Other
Unknown family history
Family Eye History
Macular Degen:
No
Parents
Siblings
Grandparent
Other
Cataracts:
No
Parents
Siblings
Grandparent
Other
Retinal Detach:
No
Parents
Siblings
Grandparent
Other
Glaucoma:
No
Parents
Sibling
Grandparent
Other
Crossed/Lazy:
No
Parents
Siblings
Grandparent
Other
Social History
Occupation:
Student
Police officer
Teacher
Nurse
Salesman
Firefighter
Engineer
Other
Hobbies:
None
Art
Baseball
Astronomy
Boating
Basketball
Cooking
Crafts
Dancing
Diving
Football
Fishing
Golf
Gardening
Horseback Riding
Hunting
Models
Needlepoint
Painting
Photography
Piano
Reading
Running
Roller Blading
Softball
Sewing
Skiing
Soccer
Swimming
Tennis
Video Games
Woodworking
Other
Any STD's?:
None
Gonorrhea
Syphilis
Hepatitis
HIV
TB
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
Type:
None
Cigarettes
Chewing Tobacco
Other
How Long:
Alcohol:
No
Yes
Occasionally
Socially
Other
Type:
None
Beer
Wine
Hard Liquor
Other
How Long:
Illegal Drugs:
No
Yes
Other
Type:
How Long:
Race:
White
Black or African American
Asian
Patient Declined to Specify
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Other Race
Other
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Unknown
Patient Declined to Specify
Other
Preferred Language:
English
French
German
Spanish
Other
Submit Data