Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev. Fr. Miss

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	Divorced Domestic partner Married Never Married 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. Fr. Miss

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:	AETNA BCBS BCBS ADVANTAGE CARE IMPROVEMENT PLUS CHIP MOLINA CHIP SUPERIOR CIGNA ENTRUST EYEMED HUMANA MEDICARE MEDICARE SUPPLEMENTAL MEDICO NEXCALIBER SCOTT & WHITE HEALTH PLAN SCOTT & WHITE SENIOR CARE SELF PAY SPECTERA SUPERIOR A&M SUPERIOR VISION TML MULTISTATE IEBP UMR UNITED HEALTHCARE VISION SERVICE 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:	AETNA BCBS BCBS ADVANTAGE CARE IMPROVEMENT PLUS CIGNA ENTRUST HUMANA MEDICARE MEDICARE SUPPLEMENTAL MEDICO NEXCALIBER SCOTT & WHITE HEALTH PLAN SCOTT & WHITE SENIOR CARE SELF PAY TML MULTISTATE IEBP UMR UNITED HEALTHCARE
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

What is the reason for your visit? (please also let us know if you are experiencing any eye or vision

concerns, such as blurred vision, eye pain, flashes of light, itchy or watery eyes, eye fatigue etc.)

Who is your Primary Care Physician?

Please indicate below if you use tobacco or consume alcohol

Tobacco: Current every day smoker Current some day smoker (not daily) Former smoker (no longer smokes) Heavy smoker (>10 cigs/day) Light smoker (<10 cigs/day) Never smoker (<100 cigs equiv) Smoker (current status unknown) Unknown if ever smoked Other Alcohol: None social occasional 1-2 drinks/day several drinks/day Other

Current Medications No meds OTC/Supplements

Allergies No Known Allergies

Review of Symptoms (please let us know if you have any problems listed below)

General: (fever, weight loss, weight gain, fatigue)
Ear, Nose, Throat: (allergies, sinus, cough, dry mouth/throat)
Cardiovascular: (high BP, heart surgery, vascular disease)
Respiratory: Asthma, (bronchitis, emphysema, COPD)
Genital, Kidney, Bladder: (kidney stones, frequent urination, impotence)
Muscles, Bones, Joints: (arthritis, joint pains, head/neck injury)
Skin: (growths, rashes, acne)
Neurological: (headaches, migraines, seizures)
Psychiatric: (depression, anxiety, insomnia)
Endocrine: (thyroid, diabetes)
Blood/Lymph: (anemia, cholesterol, bleeding problems)
Allerigc/Immunologic: (seasonal allergies, rhumatoid, M.S., lupus, HIV)
Gastrointestinal: (Diarrhea, constipation, ulcer, reflux)

Ocular History (please indicate if you or your family have ever been diagnosed with the following)

Cataracts:                   Self Mom Dad Sibling N/A Type:

Glaucoma:                 Self Mom Dad Sibling N/A Type:

Macular Degen:         Self Mom Dad Sibling N/A Type:

Retinal Detatchment: Self Mom Dad Sibling N/A Type:

Crossed/Lazy Eye:     Self Mom Dad Sibling N/A Type:

Other Ocular History

Date of your last eye exam? Name of your last eye doctor?

Eye Surgery or Injury: (please list any past eye surgery or injuries you have had below)

Other: (please let us know if you have had reoccuring eye conditions such as GPC, frequent styes, ulcers, etc.)

Are you currently using any prescription or OTC eye drops?

Medical History (please indicate if you or your family have a history of any of the following)

Diabetes:            Self Mom Dad Sibling N/A Type: None Type 1 Diabetes Type 2 Diabetes gestational diabetes hypoglycemic borderline, controlled by diet/excercise Other YrDx: A1C:

Hypertension:    Self Mom Dad Sibling N/A Type: None controlled by diet/excercise Other

Thyroid:            Self Mom Dad Sibling N/A Type: None Hyperthyroid Grave's Dz Hypothyroid Hashimoto's Dz Other

Cardiovascular: Self Mom Dad Sibling N/A Type: A-fib abdominal aneurism aortic aneurism heart attack lymphedema MI murmur MVP None peripheral arterial dz Raynaud's dz stroke Other

Cancer:              Self Mom Dad Sibling N/A Type: active basal cell BCC BCC bladder bone brain breast cervical colon cured esophageal leukemia liver lung lymphoma melanoma myeloma None ovarian pancreas prostate remission SCC squamous cell stomach testicular thyroid Other

Other Medical History

Major Medical Surgeries: (please list any major medical surgies you have had)

Are you currently pregnant or nursing? No Unsure Pregnant Nursing Other

If all applicable information has been filled out, please continue to the next tab to submit your online forms. Thank you!

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