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

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:

Medical Plan

Insurance Information

Insurance Name:	None Aetna Blue Cross Blue Shield Cigna Medicare
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:

Vision Plan

Insurance Information

Insurance Name:	None Davis Vision EyeMed Spectera Superior Vision 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:

Review Systems

GENERAL: Fever, weight loss, weight gain, fatigue?

Denies Denies Weight changes, fever, & fatique None Negative Other

EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat

Denies Denies ear or sinus issues Denies ear aches, sinus problems, & throat problems. None Allergies Sinus Problems Chronic Cough Dry Throat / Mouth Hard of Hearing Other

CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease

Denies Denies Heart or vascular issues Denies Heart troublem angina, murmur, or previous MI. None High BP Surgery Vascular Disease Other

RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD

Denies Denies cough or asthma Denies cough, shortness of breath, & wheezing. None Asthma Bronchitis Emphysema COPD Other

GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence

Denies Denies genital & bladder problems. None painful urination frequent urination impotence yellow jaundice Other

MUSCLES, BONES, JOINTS: Athritis, Joint Pains, Head or Neck Injury

Denies Denies back or joint issues Denies joint stiffness, back pain, impaired mobility. None joint pain stiffness swelling cramps arthritis Other

SKIN: growths, rashes, acne

Denies Denies Rash & Lesions. None pimples, warts growths rash Other

NEUROLOGICAL: Headaches, migraines, seizures

Denies Denies headache or memory loss Denies numbess, paralysis, headaches, head injuries, & Vertigo. None numbness, paralysis headache seizures migraines Denies memory loss, confusion, depression, insomia, & sleep apnea. Other

PSYCHIATRIC: Depression, Anxiety, Insomnia

Denies Denies depression or anxiety Denies, memory loss, confusion, depression, insomia. None anxiety depression insomnia Other

ENDORCRINE: Thyroid, Diabetes

Denies Denies Diabetes & Thyroid problems. None diabetes hypothyroid hyperthoyroid Other

BLOOD/LYMPH: Anemia, cholesterol, bleeding problems

Denies Denies anemia & other blood disorders. None bleeding cholestrolemia anemia Other

GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

Denies Denies ulcer & reflux disease. None Diarrhea Constipation Ulcer Acid Reflux Christmas tree stomach Other

ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus

Denies Denies allergies, itching, & sneezing. None sneezing swelling redness itching hives lupus itchy eyes and sneezing nose Other

Medical History

PATIENT MEDICAL HISTORY: HAs, Arthritis, Asthma, Diabetes, HBP, Heart, Infl. Bowel Dz, Seizures, Thyroid

Denies HTN, Heart Dx, Lung Dx, Thyroid Dx, Cancer & Inflammatory Dx - Good Health acne rosacea anemia arthritis Arthritis Asthma bronchitis Cancer Cancer breast chest cold cholesterol colitis Depression Diabetes diabetes type I diabetes type II Diagnosed As HIV+ digestive eczema emphysema epilepsy fatigue fever fibromyalgia flu Good health HBP Headaches Heart Condition heart disease herpes elsewhere herpes genital herpes ocular HX Of Drug/Alcohol Abuse hypertension Inflammatory Bowel Disease kidney problem leukemia Lupus MG myasthenia gravis MS multiple sclerosis muscular dystrophy Nursing panic disorder pregnant now psoriasis seasonal allergies Seizure Disorder shingles in the past sinus Smoking STD stroke Thyroid Disease thyroid dysfunction Ulcer urinary tract infection weight-loss Other

Injuries, Surgeries, Hospitalization

Pregnant Or Nursing:

No Yes Unsure Other

Recent Tetanus Shot:

Unknown Yes No Other

Birth Control:

None Orthotrycycline Other

Primary Care Physcian:

Doesn't Remember Doesn't Have One None Other

Last Visit:

Unknown 1 week 1 month 3 months 6 months 1 year 2 years Other

Reason For Visit:

Annual Check up Other

Systemic Meds:

None Actos Acyclovir Adderall Albuterol Allegra Altase Amaryl Amiodarone Amoxycillin Atenolol Augmentin Bactroban Buspar Captopril Carbamazepine Cefzil Celebrex Cipro Clonidin Coumadin Cozar Crestor Depakote Detrol Diclofenac Dilantin Diovan Effexor Flomax Flonase Furosamide Glucophage Glyburide HCTZ Humulin Hydrocortisone Lasix Levaquin Lipitor Lortab Metformin Methlyprednisolone MS Contin Nasacort Novalog Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Protonix Proventil Prozac Ritalin Singular Synthroid Tetracycline Topamax Valium Wellbutrin Xanax Zantac Zestril Zoloft Other

med2

Actos Acyclovir Adderall Albuterol Allegra ALtase Amaryl Amiodarone Amoxycillin antidepressant medication unspecified Atenolol Augmentin Bactroban Buspar Captopril Carbamazepine Cefzil Celebrex Cipro Clonidin Coumadin Cozar Crestor Detrol Diclofenac Diovan Dpakote Effexor Flomax Flonase Furosamide Glucophage Glyburide HCTZ Humulin Hydrocorisone Lasix Levaquin Lipitor Lortab Metformin Methlyprednisolone MS Contin Nasacort Novalog Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Protonis Proventil Prozac Ritalin Singular Synthroid Tetracyclin Topamax Valium Wellbutrin Xanax Zantac Zestril Zoloft Other

med3

Actos Acyclovir Adderall Albuterol Allegra Altase Amaryl Amiodarone Amoxycillin Atenlol Augmentin Bactroban Buspar Captopril Carbamazepine Cefzil Celebrex Cipro Coumadin Cozar Crestor Depakote Detrol Diclofenac Dilantin Diovan Effexor Flomax Flonase Furosamide Glucophage Glyburide HCTZ Humulin Hydrocortisone Lasix Levaquin Lipitor Lortab Metformin Methlyprednisolone MS Contin Nasacort Novalog Oxycodone Pepecid Plaquenil Plavix Prednisone Premarin Prempro Protonix Proventil Prozac Ritalin Singular Synthroid Tetracyclin Topamax Valium Wellbutrin Xanax Xantac Zestril Zoloft Other

med4

Actos Acyclovir Adderall Albuterol Allegra Altase Amaryl Amiodarone Amoxycillin Atenolol Augmentin Bactroban Buspar Captopril Carbamazepine Cefzil Celebrex Cipro Clonidin Coumadin Cozar Crestor Depakote Detrol Diclofenac Dilantin Diovan Effexor Flomax Flonase Furosamide Glucophage Glylburide HCTZ Humulin Hydrocortisone Lasix Levaquin Lipitor Lortab Metformin Methlyprednisolone MS Contin Nasacort NOvalog Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Protonix Proventil Prozac Ritalin Singular Synthroid Tetracyclin Topamax Valium Wellbutrin Xanax Zantac Zestril Zoloft Other

med5

Actos Acyclovir Adderall Albuterol Allegra Altase Amaryl Amiodarone Amoxycillin Atenolol Augmentin Bactroban Buspar Captopril Carbamazepine Cefzil Celebrex Cipro Clonidin Coumadin Cozar Crestor Depakote Detrol Diclofenac Dilantin Diovan Effexor Flomax Flonase Furosamide Glucophage Glylburide HCTZ Humulin Hydrocortisone Lasix Levaquin Lipitor Lortab Metformin Methlyprednisolone MS Contin Nasacort NOvalog Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Protonix Proventil Prozac Ritalin Singular Synthroid Tetracyclin Topamax Valium Wellbutrin Xanax Zantac Zestril Zoloft Other

med6

Actos Acyclovir Adderall Albuterol Allegra Altase Amaryl Amiodarone Amoxycillin Atenolol Augmentin Bactroban Buspar Captopril Carbamazepine Cefzil Celebrex Cipro Clonidin Coumadin Cozar Crestor Depakote Detrol Diclofenac Dilantin Diovan Effexor Flomax Flonase Furosamide Glucophage Glylburide HCTZ Humulin Hydrocortisone Lasix Levaquin Lipitor Lortab Metformin Methlyprednisolone MS Contin Nasacort NOvalog Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Protonix Proventil Prozac Ritalin Singular Synthroid Tetracyclin Topamax Valium Wellbutrin Xanax Zantac Zestril Zoloft Other

Glaucoma Meds

alphagan betagan betimol betoptic CAI cosopt Diamox glaucoma med unspecified iopidine lumigan neptazane ocupress ocusert optipranolol pilocar propine HS gel rescula Timoptic travatan trusopt Trusopt xalatan Other

Eye Meds:

None acular acular adsorbonac alamast alocril alomide Alphagan alrex Alrex antibiotic topical unspecified bacitracin bepreve Bepreve Bleph 10 Blephamide Blink cetapred ciloxan compliance with glaucoma meds cromlom Cromolyn NA 4% Decadron eflone elestat Elestat erythromycin flarex fluor-op FML FML forte FML UNG gentamicin Genteal inflamase forte lacrilube livostin lotemax Lotemax Lotemax maxidex Maxitrol medication compliance metimyd muro128 ung NaCl ointment neosporin no reported ocular meds not compliant with ocular medications ocufen ocuflox pataday Pataday Patanol Patanol polysporin polytrim Pred forte Pred Forte pred G. Refresh refresh ointment restasis rewetting drops steroid unspecified Systane tears natural ointment tetracycline Theratears Tobradex tobramycin tobramycin Tobrex Travatan vasocidin vexol Vigamox vira A viroptic Visine voltaren Xalatan zaditor zylet Other

Drug Allergies:

NKDA Codeine Penicillin SIlicone SCL Sulfa Other

OTC:

None Acetomenophin artificial tears Asprin Ibuprofen napcon A opcon A Visine Other

Vitamins:

None A E C Zinc Xanten Lutein icaps ocuvite Maxi vision eye promise Other

FAMILY MEDICAL HISTORY: Diabetes, HBP, Heart Dz, Cancer, Athritis, Lupus, Kidney, Thyroid, Other

None Adopted Athritis Cancer Cardiovascular Disease Diabetes HBP Kidney Disease Lupus Thyroid Other

fmh2

None Adopted Athritis Cancer Cardiovascular Disease Diabetes HBP Kidney Disease Lupus Thyroid Other

fmh3

None Adopted Athritis Cancer Cardiovascular Disease Diabetes HBP Kidney Disease Lupus Thyroid Other

fmh4

None Adopted Athritis Cancer Cardiovascular Disease Diabetes HBP Kidney Disease Lupus Thyroid Other

fmh5

None Adopted Athritis Cancer Cardiovascular Disease Diabetes HBP Kidney Disease Lupus Thyroid Other

fmh6

None Adopted Athritis Cancer Cardiovascular Disease Diabetes HBP Kidney Disease Lupus Thyroid Other

Occupation:

Hobbies:

Art Baseball Boating Basketball Cooking Crafts Dancing Diving Football Fishing Golf Gardening Models None Painting Photography Piano Reading Running Softball Sewing Skiing Soccer Swimming Tennis Video Games Woodworking video games Sleeping Internet drawing Shopping Volleyball Other

Tobacco:

No Yes Other

Type:

None Cigaretts 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:

STD:

None Gonorrhea Syphilis Hepatitis HIV TB Other

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