Online Patient Form
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Patient Information
Title
First
Last
MI
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Mrs.
Ms.
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Address:
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How did you hear about us?:
Billing Information
Is The Billing Address the Same?
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
City:
State:
TX
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
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MS
MO
MT
NE
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OK
OR
PA
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VI
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WA
WV
WI
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Zip Code:
Home Phone:
Work Phone:
Medical Insurance
Insurance Name:
None
3M Company
AAG
AAL
Aarp Group Health Ins
AARPHLTH
ABDI
ACORDIA
ADVANCE
Advantica
ADVANTRA
AENTA
Aetna
Aetna
Aetna Better Health Inc
Aetna Life Insurance Company
Aetna Life Insurance Company
Aetna Senior Supplemental Ins
AETNAALU
AETNAARC
AETNABP
AETNACOP
AETNACT
AETNADOW
AETNADU
AETNAENT
AETNAEQU
AETNAEXX
AETNAGLO
AETNAGRA
AETNAIND
AETNAMCI
AETNAMED
AETNAMIL
AETNANAB
AETNANOV
AETNAPC
AETNAPEP
AETNAPER
AETNAPIL
AETNAREI
AETNAROC
AETNASMU
AETNASNA
AETNATEX
AETNATWK
AETNATX
AETNAUPS
AETNAUSH
AETNAWRD
AFLAC
AGCGROUP
AHCCCS
AIM
ALASKATE
ALIC
ALLIANZ
Allied Benefit Systems
ALLSTATE
AMA
AMADMGRP
AMCOMMUN
AMCOMMUT
AMERICAN
American Continental Insurance
American Family Insurance Co.
American Republic Corp
American Retirement Life Ins Co
American Slovenian Catholic Uni
AMERICFM
Amerihealth Administrators
AMERIREP
AMERNATL
AMERREP
AMERREPU
AMFAMLIF
AMSMECH
ANTBCBS
ANTHEM
APWU/Health Plan Claims Dept.
ARM
ARPACK
ARTRANS
Associated Benefits Corporation
Assurant-Time Ins. Co.
Assurant Health
Assured Life Association
AUTOBENE
Automatic Sprinkler Fitters
Automobile Mech Local 701
Avma Group Health & Lif Ins
BAKUNION
Bankers Life And Casualty
BASMELEM
BASSE
BBAUTO
BBSIL
BCBCIL
BCBCSIL
BCBS
BCBS FEP Vision
BCBS Of IL HMO
BCBSAL
BCBSAR
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BCBSCHOI
BCBSEMNY
BCBSIIL
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BCBSIOWA
BCBSMI
BCBSMN
BCBSMO
BCBSNCA
BCBSNJ
BCBSOFMA
BCBSOMM
BCBSPA
BCBSSIL
BCBSTN
BCBSTRIG
BCBSTX
BCBSUT
BCBSVA
BCBSWIS
BCBSWV
BCCALIF
BEATTY
BEECH
BEECHST
Benefit Administrative Systems
Benefit Administrative Systems
Benesight
BENESMCD
BENESYS
BENGROUP
BENSIGHT
BIGR
Blue Cross Blue Shield Of Ill.
Blue Cross Blue Shield/Medicare
Blue Cross Community
BLUECROS
BLUECRSS
BOBTODS
Boggs & Fillenwarth, Ltd
Boilermakers Natl.H&W
BRICKLYR
BSBSIL
BSSI
BSSIDIOC
CANNON
CAREMARK
CARGILL
CARMRKAZ
CARPENT
Carpenters Welfare Fund-Illinois
CARPENTR
CARPNTWC
CARPTEN
CARPTRCH
CARPWEL
CAT
CATAPILL
CATCOMP
CCMSI
CCN
CCNFL
CCREDIMX
Celtic Insurance Company
CENRESLI
CENSTHLT
CENTBENE
CENTRAL
Central States Indemnity
CENTSTAT
CGIC
CHAMPUS
ChampVA
CHANDLER
CHESLFE
CHGPAINT
Chicago District Council Of Carp
Chicago Laborers' Hlth & Welfare
CHICTILE
CHLABWEL
CHRSBROS
CIGMAGEL
Cigna
CIGNA
Cigna-GWH
Cigna-State Of Illinois
Cigna Healthcare
Cigna Medicare Supplement
Cigna Vision, Claims Dept.
Cigna/Connecticut General Life
CIGNAADA
CIGNACA
CIGNACNT
CIGNACT
CIGNADE
CIGNAIL
CIGNAILL
CIGNAMLE
CIGNANC
CIGNANCS
CIGNAOH
CIGNASHT
CIGNATN
CIGNATX
CIGNPA
CINERGY
CINGA
City Of Morris
CMI
CMS
CNAMAIL
COLE
Colonial Penn Life Insurance
COLONPEN
Combined Ins Co Of America
Combined Medicare Supplement
COMBINS
Companion Life Insurance Co.
CONCERT
CONCORD
CONGENAZ
Connecticut General Life Ins Co
Conseco Life Insurance Co
Conseco/Washington National
CONSHLTH
CONSLIFE
CONSODAN
CONSTIT
Constitution Life
CONSWKRS
Continental Life Insurance Co
CONTINTL
CONTRYCO
CORESCE
CORESCMA
CORESOUR
CoreSource
CoreSource
CORESRCE
CORESTAR
CORESTR
COUNTLIF
COUNTRCO
Country Co Life Insurance
COUNTRYI
Coventry Health Care
CRAWFORD
Custom Design Benefits/Global
Cypress Benefit Administrators
DBLSERV
DCONST
DCONSTR
Dean Health Plan
Department Of Veterans Affairs
Dept Of Veterans Affairs
DESTINY
DESTINYG
DHS
DICKCORP
DIST131
DIST54
Division Of Sp. Care -Children
DOCSDRUG
DSCUIC
EAR
EBC
EBSIL
ECPA
Edward Hines Jr VA Hospital
Elite Administrations & Ins
EMPBMGMT
EMPHLTHI
Envolve Benefit Options
EQUITABL
Equitable Life Assur Soc Of US
Equitable Life Insurance
EVENSON
EVOLUTIO
EXELON
Eye Quest
EYEMED
F9NOTE
Family Health Network
Family Life Ins Co
Federated Ins Co - HC06
Federated Insurance
FEDERINS
FEP Blue Vision
FHEALTH
FIRHEALT
FIRSTADM
FIRSTHL
FIRSTHLH
FIRSTHLT
FIRSTHTH
FISERV
FJMETALS
FMH
Fore Thought Adm Ofc
FORTIS
FORTISIN
FOUNBENE
FOX
Fox Valley & Vicinity Constructn
Fox Valley Laborers Welfare Fund
FOXDEVMT
FRAFLEET
Freedom Life
G.M.P.-Employers Retiree Trust
Gallagher Bassett
Gallagher Bassett Services
GALLBENE
GARDLION
GARDNER
Gateway
GBA
GE Medical Benefits/ UHC
GE Vision Care Benefits
GEBCBS
GEFINANC
GEGROUP
GEHA
GEHEALTH
GELIFE
GENAMER
Gerber Life Insurance Co
GHI
GILSBAR
GLOBEACC
GLOBELIF
Golden Rule
GOLDNRUL
Government Personnel Life Ins Co
GRAINCO
GREAT
Great West
GREATWST
GREATWT
GREENWAY
GROUP
GROUPADM
GRTWEST
GRUNDY
Grundy County
Grundy County Special Education
Guarantee Trust Life Insurance
GUARD
Guardian
GUARDIAN
Guardian Vision
GWHCIGNA
Harmony Health Plan Of Illinois
HARRBENE
Hartford Life Ins
HARVESTL
HBSGROUP
Health Alliance
Health Alliance Connett
Health Alliance HMO
Health Alliance Medical Plans
Health Alliance Medicare
Health Net Federal Services
Health Network, Inc.
HEALTHLI
Healthlink
HealthLink Open Access
Healthnetwork
HealthSCOPE
HEALTHTX
Heartland National
Heartland National
HEARTLND
Heat & Frost Insulators/Local 17
HEATHSTR
HERITNAT
HEWITT
HFN, Inc.
HIGHBCBC
HIGHBCBS
Highmark Blue Cross Blue Shield
Highmark Health Services Co
HINZ
HLTHDIRE
HLTHMARC
HLTHNTTX
HLTHSMRT
HMADM
HMO
HMS
HNJUPITE
Holsinger & Associates Ltd
HOMESHEI
HORACEMA
HPM
HUBBARD
Humana
Humana
Humana Insurance Company
Humana/Medicare
HUMANAHL
IAC
IADA
IBEW
IBEW Local 134
IBEW Local 461 Welfare Fund
IBEW176
ICARE
ICHA
IDA
IdeaLife Insurance Company
IDEANLIF
IDHA Early Intervention Services
IDPA
IHC HS
ILHLTCAR
Illinois Dept Of Public Aid
Illinois Dept Of Public Aid
Illinois Dept Of Transportation
Illinois Health Partners
Illinois Public Aid
ILLTRUCK
ILPUBAID
IMA
IMAUNICA
IMED
INPR204
INSMGMT
INSTROOF
INTRCARE
IPMG Employee Benefits Service
Iron Worker's Local 63
IRONWORK
ITW
J
JACOBS
JALDEN
JEWEL
JFMOLLOY
JMAUTO
JOHNALDN
JOHNDEER
Kaiser Permanente Ins Co
KIRK-VAN
Kirke Van Orsdel/Seabury & Smith
KRAFF
LABOR75
LABORER
LABORS
LABORS75
Land Of Lincoln Health Claims
LAR
LATIMER
LCS
LGHP
LINCOLN
Lincoln Heritage Life Ins Co
LINECO
LIONS
Local 399 I.U.O.E.
Local 705 Health And Welfare
Local 710, IB Of T Hlth & Welf
Local 731 Health & Welfare Fund
LOCAL09
LOCAL125
LOCAL150
LOCAL179
LOCAL185
LOCAL364
LOCAL502
LOCAL74
LOCAL75
LOCAL76
LOCAL803
LOCAL881
LOCAL9
LOCAL996
Loyal American Ins Co
LST
LUMENOS
LYONMET
MAA
Mail Handlers Benefit Plan
Mail Handlers Benefit Plan
Manhattan Life Insurance Company
Marsh Affinity Group Services
MCDTPA
MCO
Mcsupply Jurisdiction C
MEADE
MECO
MEDBEN
MEDCOMP
MEDIAR
Medica United Healthcare
MEDICAL
Medical Mutual
Medical Mutual Of Ohio
MEDICARE
Medicare DMEPOS Assigned
Medicare DMEPOS Jurisdiction D
Medico Life Insurance Co.
MEDICOMD
MEDICOMP
MEDICRRD
MEDTAC
MEDUHC
MEGALIFE
Mercer Administration
Meridian Health Plan ATTN:Claims
METLIFE
METOKOTE
METROPOL
MGIS
MICACARE
MIDCHOIC
MIDSECUR
Midwest National Insurance
Midwest Operating Engineers
MINLIONS
MMEDICAL
MOE
MOHAWK
Monumental Life Insurance Co
MORHOSP
MORILION
MORISLIO
MORLIIOS
MORLION
MORLIONS
MORRIS
MORRISL
MORRISON
MORRLION
MRBNZCCN
MSA
MSAILL
MSAOH
MSI
MultiPlan
Mutual Of Omaha
MUTUALOM
MUTULINS
MVK
MVP Health Care
NAEDA
NALCO
NAMERINS
NARVICK
NASE
NATAUTSP
NATIONAL
National Assoc. Letter Carriers
NATLIFEI
NATRAVEL
NATSTATE
NEA
NECA-IBEW Local 176
NEDICAR
NEF
Neihbp
NELSNFUR
NETLCRCC
New Era Life Insurance Company
New York Life Insurance Co
NEWARKB
NEWYORK
NGS CoreSource
NGS Medicare
Nicor Gas
NILLBFND
Nippon Life Ins Co. Of America
NOAMER
North American Administrators
North American Administrators
North Central Illinois Laborer's
NORTHVW
NORTHWES
NOVA
NPPN
NPPNCONS
OBRIEN
OLBROT
OptiCare Vision Plans
OSF Health Plans
OSFHLTH
OSFHMO
Oxford Life Insurance Company
OXFORDHL
PACIFI
Pacific Life And Annuity
PACIFICL
PacificSource Health Plans
PAI
Painters District Council No 30
Palmetto GBA/RR Medicare
Park Point Healthcare & Rehab
PBA/Reed Custer School Dist
PBPBENE
PBS
PCM
Pekin Life Insurance Co
PENNLIFE
PERSCA
PERSCARE
PERSNL
PERSONAL
PGS
PHCS
PHCSAZ
PHCSIL
PHCSMULT
PHCSPRIN
Philadelphia American Life Ins
PHOENIX
PHYBETRU
Physician'S Mutual Insurance
Physicians Mutual
PHYSMUT
PIONEER
PIONLIFE
Pipefitters Local 430 Welfare
Pipefitters Local 597
Pipefitters Local 636
Plumber's Welfare Fund Local 130
Plumbers & Pipefitters Local 25
Plumbers & Pipefitters Local 422
Plumbers & Pipefitters Local 501
Prairie States Enterprises, Inc
PRECISIO
PREFER
PREFERD
PREFERED
PREFERPL
Preferred Care
PreferredOne Administrative Ser
PREFHCH
PRINCIP
Principal Life Ins Co
Principal Life Ins Co
Principal Life Ins Co
Principal Life Insurance
Principal Life/Cedar Rapids Cnt.
PRINCIPL
PRINCLFE
PRIVAT
PRIVATE
PRMUTUAL
PROAMERC
Professional Benefit Adm,Inc.
Professional Benefit Admin
PROFFBEN
PROGRES
PRONET
PROVAMER
PROVIDET
PROVIDIA
PROVIDIN
PRUDATT
PRUDENHC
PRUDENT
PRUDENTL
PRUDINSC
PUP
Pyramid Claims
Pyramid Life
QCHP
R. E. Harrington, Inc.
RAILROAD
RBOUCK
Regency Care Of Morris
Regency Employee Benefits
REGLFHLT
REICHEM
REICHOLD
RENALCAR
RENDELS
Reserve National Ins Co
Retiree Medical Ins Plan
Rigazio & Bertani
RONSAUTO
ROOFERS
Royal Neighbors Of America
RPIVATE
RSL
Rural Carrier Benefit Plan
RUSHPRUD
Sagamore Healthnetwork, Inc
SAGETECH
Samba Federal Health Plan
SAMBAMD
Sanford Health Plan
SAUER
SAUERWEL
Seabury And Smith
SEAFARER
SECURE
Select Benefit Administrators
SENECA
SENECALI
SENECALN
Senior Care Partners
SENIORCR
SENLIONS
SENTRY
SFARMMUT
Sheet Metal Wkrs #265
Sheet Metal Worker'S Health Fund
Sheet Metal Worker's Local 73
Sheet Metal Workers Local 265
SHEETMTL
Silver Cross Managed Care
Sisco
SMURFIT
SPECTERA
SPONGECU
SRC
STANDARD
Standard Life & Accident Ins Co
Standard Life And Health
STAR
STARHRG
Starmark
State Compensation Fund
State Compensation Ins Fund
State Farm Insurance
State Farm Insurance Co
State Mutual Insurance Co.
STATEFRM
STERLIFE
STERLING
STFARMBL
STFARMIN
STFRMAUT
STLIFE
Student Insurance/NIU
SUBRTEAM
Suburban Teamsters Welfare Fund
SUPERIOR
TCHP
TEAM673
TEAMSTER
Teamsters Local 734
TEAMSTES
TEAMSTRS
The Hartford Medical Ins Plans
The Mega Life & Health Ins. Co.
THETPA
Thrivent For Lutherans
TIRETRKS
TLC LASER CENTER
TPADST58
TPAMCD
TPASTEPN
Transamerica Life Ins Co
TRAVELER
TRICAR
Tricare North Region
Tricare Prime R2/5
Trinity Services
TRUST
TRUSTMAR
Trustmark Ins Co
Trustmark Insurance Company
UCC
UCCHARR
UCH
UFCWMIDW
UHC Caterpillar
UHC Group Medicare Advantage PPO
UHC Student Resources
UHCAIRBO
UHCAMAIR
UHCATT
UHCCITGO
UHCGTE
UHCHMO
UHCILL
UHCOPEN
UHCS
UHCSELEC
UHCUNROY
UHCVISN
UHCWILL
ULLICARE
UMWA Health & Retirement Fund
Uni Care
UNICARCA
UNICARDW
Unicare
Unicare
Unicare Life & Health Ins Co
Unicare Life & Health Ins. Co.
UNIFIRST
UNION
UNIONBAN
UNIONLAB
UNIROYAL
UNITCOM
UNITCOMM
UNITDMED
UNITED
United American Ins
United American Insurance
United Commercial Travelers
United Food & Com Workers
United Health Care
United Healthcare
United Healthcare
United Healthcare
United Healthcare Medicare HMO
United Healthcare River Valley
United Medical Resources
United Medical Resources
United Medical Resources,Inc
United National Life Insurance
United Security Life Ins Co
UNITEDHE
UNITEDTE
UNIVHEAL
Usaa Life And Health Ins
USAHLTH
USARMYCO
USHLTHLF
VANDRUN
Veterens Choice
VISION
VSN
VSP
WALGREEN
WASHMUTU
WAUBEN
WAUSAU
WELLHLTH
WELLMARK
Western Catholic Union
Will County Local 174
WILLCARP
WILSON
WIS
WKMNCOMP
WKMNSCOM
WKMSCOMP
Woodmen Of The World/Assur Life
WOODWARD
WORKCOMP
WORKMAN
WORKMANS
WORLDINS
WORMANS
WPS
WPS/Tricare For Life
Zurich North America
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
Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!
Reason for Visit:
Secondary Reasons:
Medications:
No Meds Used
Over The Counter Medications:
Vitamins:
Drug Allergies:
No Known Drug Allergies
Please describe any injuries or surgeries you have had:
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 Or Nursing:
No
Yes
Unsure
Other
Recent Tetanus Shot:
Yes
No
Other
Do you or anyone in your family have the following medical conditions?:
Unknown family history
Diabetes:
None
Self
Mother
Father
Grandparent
Unknown
Other
Type:
Type 1
Type 2
Other
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
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
Want contacts?
Yes
No
Other
Do you want to discuss LASIK with the doctor?:
Yes
No
Other
Do you have any of the following eye conditions?:
Glaucoma
Cataracts
Macular Degeneration
Crossed/Lazy Eye
Retinal Detachment
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
hyperthyroid
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
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
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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