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
Misc/Guardian

Is the Billing Address Different?

Billing Information

Address Same As Above

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

Primary Vision Insurance Information

Insurance Name:	None Aetna Medical Aetna Vision Always Care Starmount Ameritas Avesis BCBS of TX Medical Blue View Vision Cigna Medical Cigna Vision Davis Vision Eyemed Humana Medical Humana VCP Humana Vision Spectera Superior United Healthcare Medical United Healthcare Vision Vision Benefits of America (VBA) 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 Vision Insurance Information

Insurance Name:	None Aetna Medical Aetna Vision Always Care Starmount Ameritas Avesis BCBS of TX Medical Blue View Vision Cigna Medical Cigna Vision Davis Vision Eyemed Humana Medical Humana VCP Humana Vision Spectera Superior United Healthcare Medical United Healthcare Vision Vision Benefits of America (VBA) 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

Primary Medical Insurance Information

Insurance Name:	None Aetna Medical Aetna Vision Always Care Starmount Ameritas Avesis BCBS of TX Medical Blue View Vision Cigna Medical Cigna Vision Davis Vision Eyemed Humana Medical Humana VCP Humana Vision Spectera Superior United Healthcare Medical United Healthcare Vision Vision Benefits of America (VBA) 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 Medical Insurance Information

Insurance Name:	None Aetna Medical Aetna Vision Always Care Starmount Ameritas Avesis BCBS of TX Medical Blue View Vision Cigna Medical Cigna Vision Davis Vision Eyemed Humana Medical Humana VCP Humana Vision Spectera Superior United Healthcare Medical United Healthcare Vision Vision Benefits of America (VBA) 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

Visual History

Please list any eye issues you're currently having:

What pharmacy do you normally use?:

Previous Eye Doctor:

Last Eye Exam

1 year 2 years 3 years Other

Age of Glasses:

Primary Vision Correction:

None Glasses-Full Time Glasses-Readers Only Contacts - Soft RGPs PMMA OTC readers Other

Type of contacts worn in past:

None Disposable Conventional Colored RGP PMMA Cobalt Study Lens Soft Other

Solution:

None PureMoist Optifree Clear Care Boston Renu Biotrue Aquify Other

Disposal:

daily 2 weeks monthly weekly yearly Other

*Have you ever had any medical attention to your eyes? Please describe:

Past, Current and Family History of Eye Conditions

	You	Family	No
Cataract
Lazy Eye
Glaucoma
Computer Vision Syndrome
Macular Degeneration
Vitreous Detachment
Retinitis Pigmentosa
Retinal Detachment
Color Blindness

Please describe any other history of eye disease:

Please describe any other family history of eye disease:

Medical History (problems with bodily systems)

	You	Family	No
Diabetes
Gastroinestinal
Ear/Nose/Throat
Cardiovascular
Respiratory
High BP
Nervous System
Genitourinary
Musculoskeletal
Mental System
Endocrine
Blood/Lymph
Allergy/Immune
Allergies
Medication Use

Please describe any other history of medical conditions:

Please describe any other family history of medical conditions:

Do you currently have any allergies?:

Please list any medications you're currently taking:

Vitamins:

None A E C Zinc Xanten Lutein Other

Over The Counter Meds:

None Asprin Acetomenophin Ibuprofen Other

Pregnant Or Nursing?:

No Yes Unsure Other

Have you had a:     Recent Tetanus Shot?:

Yes No Other

Recent Flu Vaccine?:

Yes No Other

Social History

How often do you use a computer?:

Workplace Setting:

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

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 Use:	No Yes Occasionally Socially Other	Type:	None Beer Wine Hard Liquor Other	How Long:
Illegal Drug Use:	No Yes Other	Type:		How Long:

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