Online Patient Form
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Demographics
Patient Information
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
City:
State/ZipCode
CA
AL
AK
AZ
AR
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
TX
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. BALES, DENNIS
Dr. NELSON, TIMOTHY
Misc/Guardian
Billing Information
Is The Billing Address the Same?
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Address
City
State
ZipCode
CA
AL
AK
AZ
AR
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
TX
Home Phone:
Work Phone:
Primary
Insurance Information
Insurance Name:
None
New Insurance
Aetna HMO
Americare
Anthem Blue Cross HMO
ART OPTICAL
Aspex
Assigned Fee Schedules
Auto Club of Southern CA
Blue Cross-Blue Shield of CA
Blue Cross PPO
Blue Cross Senior Classic J
Blue Shield-Medicare
Blue Shield (MES)
Blue Shield PPO
Central Coast Water Authority
CIGNA Healthcare
Corsource
County of Santa Barbara
Eyemed Vision Care Plan
GEHA
Generic Payer
Healthnet
Healthnet Senority Plus
HMO- Sansum Santa Barbara Medical Foundation Clini
Managed Care Administrators
Medical Eye Services
Medical/Santa Barbara Regional Health Initiative
Medicare Southern CA
Mutual of Omaha
Pinnacle Claims
Principal Life Insurance Company
Santa Ynez Tribal Health Clinic
Self Pay
Southern California Food & Commodities Union
Southern California Pipe Traders Trust Fund
Superior Vision Plan
Teamsters Benefit Trust
Transamerica Life Insurance Company
United American Insurance
United Health Care
VSP
Writer's Guild - Industry Health Fund
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
New Insurance
Aetna HMO
Americare
Anthem Blue Cross HMO
ART OPTICAL
Aspex
Assigned Fee Schedules
Auto Club of Southern CA
Blue Cross-Blue Shield of CA
Blue Cross PPO
Blue Cross Senior Classic J
Blue Shield-Medicare
Blue Shield (MES)
Blue Shield PPO
Central Coast Water Authority
CIGNA Healthcare
Corsource
County of Santa Barbara
Eyemed Vision Care Plan
GEHA
Generic Payer
Healthnet
Healthnet Senority Plus
HMO- Sansum Santa Barbara Medical Foundation Clini
Managed Care Administrators
Medical Eye Services
Medical/Santa Barbara Regional Health Initiative
Medicare Southern CA
Mutual of Omaha
Pinnacle Claims
Principal Life Insurance Company
Santa Ynez Tribal Health Clinic
Self Pay
Southern California Food & Commodities Union
Southern California Pipe Traders Trust Fund
Superior Vision Plan
Teamsters Benefit Trust
Transamerica Life Insurance Company
United American Insurance
United Health Care
VSP
Writer's Guild - Industry Health Fund
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!
Chief Complaint
Reason for Visit:
Blurrred vision
Annual eye exam; no problems
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
Location:
Both eyes
Right eye
Left eye
Other
Severity:
Mild
Moderate
Severe
Other
Quality:
no change
worse
better
constant
throbbing
slightly worse
a little better
much better
Vision is good
Other
Duration:
ongoing
1 day
2 days
3 days
4 days
5 days
6 days
1 week
1 month
3 months
6 months
1 year
Other
Timing:
Always
Sometimes
AM
PM
Other
Context:
computer
outside
reading
driving
tv
school
Other
Modifying:
Medication
Glasses help
Drops help
Contacts Help
Other
Associated:
dizzy
headache
loss of vision
blurred vision
eye pain
Other
Secondary Reasons:
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
Location:
Both eyes
Right eye
Left eye
Other
Severity:
Mild
Moderate
Severe
Other
Quality:
no change
worse
better
constant
throbbing
slightly worse
a little better
much better
Vision is good
Other
Duration:
ongoing
1 day
2 days
3 days
4 days
5 days
6 days
1 week
1 month
3 months
6 months
1 year
Other
Timing:
Always
Sometimes
AM
PM
Other
Context:
computer
outside
reading
driving
tv
school
Other
Modifying:
Medication
Glasses help
Drops help
Contacts Help
Other
Associated:
dizzy
headache
loss of vision
blurred vision
eye pain
Other
Review of Ocular System
Please describe any eye problems/conditions you have/had:
Eye Medications:
None
Alrex
Alphagan
Blink
Cromolyn NA 4%
Elestat
Genteal
Lotemax
Rewetting drops
Patanol
Pred Forte
Refresh
Restasis
Travatan
Theratears
Systane Balance
Systane Ultra
Vigamox
Visine
Xalatan
Other
Last Eye Exam:
1 year
2 years
3 years
Other
By Doctor:
Dr. Dennis R. Bales
Dr. Timothy L. Nelson
Dr. Robert Avery
Dr. Stephen Bylsma
Dr. Alessandro Castellarin
Dr. Stephen Couvillion
Dr. Ryan Fante
Dr. Randall Goodman
Dr. Doug Katsev
Dr. Doug King
Dr. Robert Kolarczyk
Dr. Marc Lowe
Dr. Bryant Lum
Dr. Toni Meyers
Dr. Ma'an Nasir
Dr. Michael Paveloff
Dr. Dante Pieramici
Dr. Robert Poulin
Dr. Marc Silverberg
Dr. Nathan Steinle
Dr. Pamela Thiene
Dr. Stuart Winthrop
Dr. Wilson Wu
Dr. Rami Zargegar
Dr. Steven Zelko
Other
Primary Vision Correction:
None
Glasses-Full Time
Glasses-Readers Only
Contacts - Soft
RGPs
PMMA
OTC readers
Other
Back up glasses?:
No
Yes
Other
Want new glasses?:
Yes
No
Other
Fill out this section
only
if you wear/have worn contact lenses.
Type of contacts worn in 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 worn comfortably:
Previous Eye Surgeries
1.
Type of Surgery:
Surgeon:
Where:
When:
Results/Complications:
2.
Type of Surgery:
Surgeon:
Where:
When:
Results/Complications:
Family Ocular History
Does your family have a history of these conditions? If yes, please choose the affected family member.
Macular Degen:
No
Mother
Father
Brother
Sister
Aunt
Uncle
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Other
Glaucoma:
No
Mother
Father
Brother
Sister
Aunt
Uncle
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Other
Cataracts:
No
Mother
Father
Brother
Sister
Aunt
Uncle
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Other
Retinal Detach:
No
Mother
Father
Brother
Sister
Aunt
Uncle
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Other
Blind:
No
Mother
Father
Brother
Sister
Aunt
Uncle
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Lazy Eye:
No
Mother
Father
Brother
Sister
Aunt
Uncle
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Other
Crossed Eyes:
No
Mother
Father
Brother
Sister
Aunt
Uncle
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Review of Systems
General:
None
Fever
Weight Gain
Weight Loss
Other
Ear/Nose/Throat:
None
Allergies/Hayfever
Sinus Problems
Runny Nose
Post-Nasal Drip
Chronic Cough
Dry Throat / Mouth
Hard of Hearing
Other
Skin:
None
Acne
Cancer
Growths
Pimples, warts
Psoriasis
Rash
Rosacea
Other
Genital/Kidney/Bladder:
None
Frequent urination
Impotence
Painful urination
Yellow jaundice
Other
Neurological:
None
Headache
Migraines
Numbness, paralysis
Seizures
Other
Cardiovascular:
None
Heart Surgery
High Bood Pressure
High Cholesterol
Vascular Disease
Other
Psychiatric:
None
Anxiety
Depression
Insomnia
Other
Muscles/Bones/Joints:
None
Arthritis
Cramps
Joint pain
Muscle pain
Swelling
Stiffness
Other
Respiratory:
None
Asthma
Bronchitis
COPD
Emphysema
Other
Allergic/Immunologic:
None
Hives
Itching
Lupus
Redness
Sneezing
Swelling
Other
Endocrine:
None
Diabetes
Hyperthoyroid
Hypothyroid
Kidney Stones
Other
Blood/Lymph:
None
Bleeding
Cholestrolemia
Anemia
Other
Gastrointestinal:
None
Acid Reflux
Constipation
Diarrhea
Ulcer
Other
Medical History
Vitamins:
Over the Counter Medications:
Primary Care Physician:
Last Visit:
1 week
1 month
3 months
6 months
1 year
2 years
greater than 3 years
Other
Reason For Visit:
Check up
Annual
Specific
Other
Pregnant Or Nursing:
No
Yes
Unsure
Other
Injuries, Surgeries, Hospitalizations?:
Do you have a history of these conditions? If yes, please describe.
Diabetes:
None
Yes
Describe:
Type 1
Type 2
Other
Year Diagnosed:
1 yr
2 yrs
3-5 yrs
5-10 yrs
10+ yrs
Other
HbA1C:
doesn't know
Other
Blood Pressure:
None
Yes
Describe:
High Cholesterol:
None
Yes
Describe:
High LDL
High HDL
Other
Thyroid:
None
Yes
Describe:
Hyperthyroidism
Hypothyroidism
Other
Cardiovascular:
None
Yes
Describe:
Cancer:
None
Yes
Describe:
Breast
Colon
Cervical
Lung
Melanoma
Ovarian
Pancreatic
Prostate
Skin
Stomach
Uterine
Other
Social History
Occupation:
Retired
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
STD's:
None
Gonorrhea
Syphilis
Hepatitis
HIV
TB
Other
Do you drive?:
Yes
No
Daytime only
Other
Any issues?:
Distant signs blurry
No driving issues if wearing corrective lenses
Other
Computer Use:
Yes
No
Other
Hours per day:
Monitor Height:
At eye level
Above eye level
Below eye level
Other
Distance:
12 inches
30 inches
Other
Reads:
Extensively
Daily Newspaper
Other
Do you Require:
No special needs
Additional Light
Magnifiers
Readers
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:
Many years
Other
Amount:
2 per day
3 per week
Socially only
Other
Illegal Drugs:
No
Yes
Other
Type:
How Long:
Many years
Other
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
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