Patient Form

Demographics

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	Unknown Single Married Separated Divorced Widowed Child	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Guenthner, Nancy	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 Insurance

Insurance Information

Insurance Name:	None Aetna Avesis Block Vision Blue Cross Blue Shield Cigna Davis Vision EyeMed Great-West Healthcare Humana Medicare Not Listed PHCS/Multiplan SafeGuard Scott & White Superior Vision Tricare United Healthcare Vision Care Plan/HumanaVision Vision Service Plan (VSP)
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:
Employer/School:

Vision Plan

Insurance Information

Insurance Name:	None Aetna Avesis Block Vision Blue Cross Blue Shield Cigna Davis Vision EyeMed Great-West Healthcare Humana Medicare Not Listed PHCS/Multiplan SafeGuard Scott & White Superior Vision Tricare United Healthcare Vision Care Plan/HumanaVision Vision Service Plan (VSP)
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:
Employer/School:

Insurance 3

Insurance Information

Insurance Name:	None Aetna Avesis Block Vision Blue Cross Blue Shield Cigna Davis Vision EyeMed Great-West Healthcare Humana Medicare Not Listed PHCS/Multiplan SafeGuard Scott & White Superior Vision Tricare United Healthcare Vision Care Plan/HumanaVision Vision Service Plan (VSP)
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:
Employer/School:

Medical History

Please fill out the questionnaire below. If you are filling this out for a child, all questions refer to the child. If you do not know the answer to a question, feel free to leave it blank. Thank you!

New Patients:
Were you referred to our office? Yes   No   Whom may we thank for this referral?
If not referred, how did you hear about us?  Check all that apply.
Yellowpages Yellowbook Community Impact Cedar Park Magazine Gold's Gym Yelp Citysearch Cat Hollow Newsletter DemandForce Insurance Location ZocDoc
Other:
VISUAL HISTORY:
Main reason for having an examination today:
Are there times when your vision (or present lens) isn't quite right?
Are there any activities you would enjoy doing, but must restrict because of your vision?
Date of last evaluation:   Doctor's name:
Results / Recommendations:
Check all that apply. I currently wear: Glasses Part-time Full-time    If part-time, how often/when?
Contact Lenses Soft Rigid Gas Permeable Part-time Full-time   If part-time, how often/when?
Are you interested in trying contacts?Yes No
Contact Lens Wearers: Are your lenses comfortable? Yes No   Current Brand:
What solution do you use?    What is your replacement schedule? Daily Weekly Every 2 weeks Monthly Quarterly Yearly   How old is your current pair?
Do you use any eyedrops (Rx or OTC)? Yes No    If yes, please list name/how often used:

Do you have a history of any of the following? YES NO Blindness Eye Turn (Strabismus) Lazy Eye (Amblyopia) Patching Vision Therapy Keratoconus Glaucoma Cataracts Macular Degeneration Retinal Detachment Other Eye Disease If yes, what disease? List any eye surgeries: Describe any eye injuries:

Do you experience any of the following? YES NO Headaches Blurred Vision Double Vision Eyes "hurt" or "tired" Nausea when doing visual tasks Motion sickness / car sickness Halos around lights Bothered by light / sun light Closing or covering one eye Frequent squinting Frequent blinking Lose place while reading Poor reading comprehension              When reading, letters/words: appear to move or float around Lose attention easily Frequent styes Eyes frequently reddened Eyes itch Eyes burn Eyes tear Eyes feel dry Eyes feel sandy/gritty Flashes Floaters

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MEDICAL HISTORY / REVIEW OF SYSTEMS:

Physician's Name:

Last Visit Date: For What Reason?

List all medications you are currently taking and dosages (including any OTC/vitamins):

Do you have any allergies to medications? Yes No

If yes, please list:

List significant illnesses, high fevers, injuries, or hospitalizations, including date and any complications:

Ladies, are you pregnant or nursing? N/A Yes No If yes, what is the due/birth date?

Do you have, or ever had, any CHRONIC problems in the following areas?
	YES	NO			YES	NO
Neurological				Cardiovascular
Migraines				High blood pressure
Seizures				High cholesterol
Multiple Sclerosis				Stroke
				Gastrointestinal
Endocrine				Genitourinary
Diabetes				Musculoskeletal
Thyroid problems				Arthritis
				Skin problems
Ear/Nose/Throat				Lymphatic/Hematological
Allergies/Hay fever				Anemia
Ear infections				Cancer
Dry throat/mouth				Psychiatric disorder
				Developmental delay
Breathing problems				ADD/ADHD
Asthma				Other
Emphysema

If you checked YES to any of the above, please explain:

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FAMILY HISTORY:

Family history is unknown/adopted
Any history of the following in any family members (parents, grandparents, siblings, children)?

	YES	NO	Relationship to Patient		YES	NO	Relationship to Patient
Poor vision				Cancer
Blindness				Diabetes
Eye turn (Strabismus)				High Blood Pressure
Lazy Eye (Amblyopia)				High Cholesterol
Glaucoma				Stroke
Cataracts				Thyroid Disease
Macular Degeneration				Other Inherited Disease
Retinal Detachment/Disease				If yes, what disease?

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SOCIAL HISTORY:
This information is required by insurance carriers and is kept strictly confidential.
However, you may discuss this portion directly with the doctor if you prefer. If so, check here:

	YES	NO
Do you use tobacco products?			If yes, type/amount/how often:
Do you drink alcohol?			If yes, type/amount/how often:
Do you use illegal drugs?			If yes, type/amount/how often:

Are you currently or have you ever been infected with:

	YES	NO
Tuberculosis
Hepatitis
HIV
Syphilis
Chlamydia

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DEVELOPMENTAL HISTORY:
Only complete the following section if the patient is an infant or toddler (3 years old or less).

Length of Pregnancy:

Type of delivery: Natural Caesarian

Forceps / Vacuum used

During pregnancy of this child, did any of the following occur:
toxemia	smoking
severe illness	use of alcohol
trauma	use of drugs
other
Please explain:
Child's birthweight: lbs. and ozs.
Apgar score: @ birth after 10 minutes

Please list all immunizations child has received and date:


Any reactions to immunizations? Yes No

If yes, please explain:

Submit

Thank you for taking the time to fill out our online History Questionnaire form.

You may click on the tabs above to review the information you have provided.

Please be sure you have filled out both the Demographics tab AND the Medical History tab and any applicable insurance tabs before clicking submit.

Click on the button below to submit your information.

Please provide at least 24 hours notice of cancellation.