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:	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		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 Vision

Insurance Information

Insurance Name:	None Advantica Aetna Medical Aetna Medicare Adv Aetna Vision Always Care - Eyemed Amerigroup STAR/CHIP Avesis Baylor - Cigna Medical Baylor Scott White BCBS Medicare Advantage BCBS of Texas BCBSTX STAR and CHIP Medicaid Better Health of TX by Aetna Blue View Vision Cigna Healthspring Medicare Advantage Cigna Medical Cigna Vision Davis OON Davis Vision Eyemed GEHA - UHC Humana Medical Humana TRS Advantage Humana Vision - Eyemed Medicare Meritain by Aetna MES Vision - Eyemed Molina Health of Texas National Vision Administrators (NVA) North Texas Specialty Physician Spectera - Optum Health Vision Superior Vision Texas Health Aetna UHC AARP MedicareComplete UHC Medicaid STAR/CHIP UHC Medical UMR - UHC Vision Benefit 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 Advantica Aetna Medical Aetna Medicare Adv Aetna Vision Always Care - Eyemed Amerigroup STAR/CHIP Avesis Baylor - Cigna Medical Baylor Scott White BCBS Medicare Advantage BCBS of Texas BCBSTX STAR and CHIP Medicaid Better Health of TX by Aetna Blue View Vision Cigna Healthspring Medicare Advantage Cigna Medical Cigna Vision Davis OON Davis Vision Eyemed GEHA - UHC Humana Medical Humana TRS Advantage Humana Vision - Eyemed Medicare Meritain by Aetna MES Vision - Eyemed Molina Health of Texas National Vision Administrators (NVA) North Texas Specialty Physician Spectera - Optum Health Vision Superior Vision Texas Health Aetna UHC AARP MedicareComplete UHC Medicaid STAR/CHIP UHC Medical UMR - UHC Vision Benefit 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:

Primary Medical

Insurance Information

Insurance Name:	None Advantica Aetna Medical Aetna Medicare Adv Aetna Vision Always Care - Eyemed Amerigroup STAR/CHIP Avesis Baylor - Cigna Medical Baylor Scott White BCBS Medicare Advantage BCBS of Texas BCBSTX STAR and CHIP Medicaid Better Health of TX by Aetna Blue View Vision Cigna Healthspring Medicare Advantage Cigna Medical Cigna Vision Davis OON Davis Vision Eyemed GEHA - UHC Humana Medical Humana TRS Advantage Humana Vision - Eyemed Medicare Meritain by Aetna MES Vision - Eyemed Molina Health of Texas National Vision Administrators (NVA) North Texas Specialty Physician Spectera - Optum Health Vision Superior Vision Texas Health Aetna UHC AARP MedicareComplete UHC Medicaid STAR/CHIP UHC Medical UMR - UHC Vision Benefit 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 Advantica Aetna Medical Aetna Medicare Adv Aetna Vision Always Care - Eyemed Amerigroup STAR/CHIP Avesis Baylor - Cigna Medical Baylor Scott White BCBS Medicare Advantage BCBS of Texas BCBSTX STAR and CHIP Medicaid Better Health of TX by Aetna Blue View Vision Cigna Healthspring Medicare Advantage Cigna Medical Cigna Vision Davis OON Davis Vision Eyemed GEHA - UHC Humana Medical Humana TRS Advantage Humana Vision - Eyemed Medicare Meritain by Aetna MES Vision - Eyemed Molina Health of Texas National Vision Administrators (NVA) North Texas Specialty Physician Spectera - Optum Health Vision Superior Vision Texas Health Aetna UHC AARP MedicareComplete UHC Medicaid STAR/CHIP UHC Medical UMR - UHC Vision Benefit 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

Reason for Visit:

Medications: No Meds Used

Drug Allergies: No Known Drug Allergies

Describe injuries/surgeries you have had:

Pregnant Or Nursing:

No Yes Unsure Other

Family Medical History Unknown family history 

Diabetes:

None Self Mother Father Grandparent Unknown Other

Type:

Type 1 Type 2 Other

Year Diagnosed:

1 yr 2 yrs 3-5 yrs 5-10 yrs 10+ yrs Other

HbA1C:

High Blood Pressure:	None Self Mother Father Grandparent Unknown Other	Describe:
High Cholesterol:	None Self Mother Father Grandparent Unknown Other	Describe:
Thyroid Disease:	None Self Mother Father Grandparent Unknown Other	Describe:
Heart Problems:	None Self Mother Father Grandparent Unknown Other	Describe:
Cancer:	None Self Mother Father Grandparent Unknown Other	Describe:

Eye History

Do you currently have any of these symptoms?:	None Itching Burning, Stinging Red Floaters Flashes Of Light Eye Injuries Eye Surgery Amblyopia Strabismus Cataracts Glaucoma Retinal Disorders Other
Do you take any of these 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 Prescription Glasses Prescription Reading Glasses Soft Contacts Non-Prescription Reading Glasses Other

Do you:    Have back up glasses?

No Yes Other

Want new glasses?

Yes No Other

Contact Lens Wearers only

Type of contacts worn in the past:

None Disposable Conventional Colored RGP PMMA Cobalt Study Lens Soft Other

Cleaner:

None PureMoist Optifree Clear Care Boston Renu Biotrue Aquify Other

Disposal:

daily 2 weeks monthly weekly yearly Other

Wear Time:

>2 hours today All day Occ. Overnight Extended 8 hours 10 hours 12 hours Overnight Other

Days per week worn:

Hours per day worn:

Family Eye History

Macular Degen:	No Parents Siblings Grandparent Other	Glaucoma:	No Parents Sibling Grandparent Other
Retinal Detach:	No Parents Siblings Grandparent Other	Cataracts:	No Parents Siblings Grandparent Other
Lazy/Crossed Eye:	No Parents Siblings Grandparent Other

Review of Systems

General:	none fatigue fever loss of appetite weight gain weight loss Other	Ear/Nose/Throat:	none chronic cough congestion daytime drowsiness dry throat / mouth gasp while sleeping headache hearing problems heavy snoring morning headaches runny nose sinus problems sleep apnea tinnitus toothache Other
Skin:	none acne eczema itching psoriasis rosacea Other	Cardiovascular:	none chest pain heart disease high cholesterol hypertension racing heartbeat shortness of breath swollen feet/ankles vascular disease Other
Respiratory:	none asthma cronchitis cyanosis emphysema productive cough shortness of breath wheezing Other	Musculoskeletal:	none arthritis decreased range of motion muscle cramps pain/tenderness stiffness swelling weakness Other
Psychiatric:	none anxiety depression insomnia obsessive/compulsive paranoia suicidal violence Other	Gastrointestinal:	none abdominal pain acid reflux bloody stools constipation Crohn's disease dark urine diarrhea gastric reflux (GERD) IBS jaundice nausea ulcer vomiting Other
Endocrine:	none diabetes hypothyroid hyperthoyroid Other	Blood/Lymph:	none anemia bleeding gums cuts slow to clot easy bruising hx of significant blood loss nosebleeds pale skin pounding in ears rapid heartbeat shortness of breath Other
Neurological:	none balance problems changes in senses dementia memory problems muscle weakness numbness, paralysis personality changes speech problems tremors vertigo Other	Genitourinary:	none impotence jaundice overactive bladder painful urination painful urination underactive bladder urgency in urination urinary incontinence Other
Immune:	none asthma hives itching mild allergy symptoms redness severe allergy symptoms sneezing swelling Other

Social History

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

STD's:

None Gonorrhea Syphilis Hepatitis HIV TB Other

Race:

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

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 Cigaretts 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