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:
Cell Phone:		Preferred Contact Method:	Text Message Cell Phone Email Work Phone Home Phone Other Phone
SSN		Email
Birthday		Occupation
Sex	Male Female
Marital Status	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous 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.

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 Plan

Insurance Information

Insurance Name:	None Aetna Always Care Avesis Blue Cross Blue Shield Cigna EyeMed Guardian Humana Medi-share Medicare Part B Other Self Pay Spectera Eyecare Networks SuperiorVision United Healthcare Vision Service Plan VIVA Health
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:

Primary Medical Insurance

Insurance Information

Insurance Name:	None Aetna Always Care Avesis Blue Cross Blue Shield Cigna EyeMed Guardian Humana Medi-share Medicare Part B Other Self Pay Spectera Eyecare Networks SuperiorVision United Healthcare Vision Service Plan VIVA Health
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:

Secondary Medical Insurance

Insurance Information

Insurance Name:	None Aetna Always Care Avesis Blue Cross Blue Shield Cigna EyeMed Guardian Humana Medi-share Medicare Part B Other Self Pay Spectera Eyecare Networks SuperiorVision United Healthcare Vision Service Plan VIVA Health
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:

Secondary Vision Plan

Insurance Information

Insurance Name:	None Aetna Always Care Avesis Blue Cross Blue Shield Cigna EyeMed Guardian Humana Medi-share Medicare Part B Other Self Pay Spectera Eyecare Networks SuperiorVision United Healthcare Vision Service Plan VIVA Health
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:

Other

Insurance Information

Insurance Name:	None Aetna Always Care Avesis Blue Cross Blue Shield Cigna EyeMed Guardian Humana Medi-share Medicare Part B Other Self Pay Spectera Eyecare Networks SuperiorVision United Healthcare Vision Service Plan VIVA Health
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!

Primary Care Physician
Last Medical Dr Appt
Last Eye Exam
Last Eye Dr
Pharmacy

Smoking Status	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 Use	None Social Use Heavy use Alcoholic Recovering Alcoholic Other
Illegal Drug	None Social Use Heavy use Other

Race	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander Other Race Patient Declined to Specify White Other
Preferred Language	English Spanish French Patient Declined to Specify Abkhazian Afar Afrikaans Akan Albanian Amharic Arabic Aragonese Armenian Assamese Avaric Avestan Aymara Azerbaijani Bambara Bashkir Basque Belarusian Bengali Bihari languages Bislama Bokm?l, Norwegian), Norwegian Bokm?l Bosnian Breton Bulgarian Burmese Catalan; Valencian Central Khmer Chamorro Chechen Chichewa; Chewa; Nyanja Chinese Church Slavic; Old Slavonic; Church Slavonic; Old Bulgarian; Old Church Slavonic Chuvash Cornish Corsican Cree Croatian Czech Danish Divehi; Dhivehi; Maldivian Dutch; Flemish Dzongkha Esperanto Estonian Ewe Faroese Fijian Finnish Fulah Gaelic; Scottish Gaelic Galician Ganda Georgian German Greek, Modern (1453-) Guarani Gujarati Haitian; Haitian Creole Hausa Hebrew Herero Hindi Hiri Motu Hungarian Icelandic Ido Igbo Indonesian Interlingua (International Auxiliary Language Association) Interlingue; Occidental Inuktitut Inupiaq Irish Italian Japanese Javanese Kalaallisut; Greenlandic Kannada Kanuri Kashmiri Kazakh Kikuyu; Gikuyu Kinyarwanda Kirghiz; Kyrgyz Komi Kongo Korean Kuanyama; Kwanyama Kurdish Lao Latin Latvian Limburgan; Limburger; Limburgish Lingala Lithuanian Luba-Katanga Luxembourgish; Letzeburgesch Macedonian Malagasy Malay Malay Malayalam Maltese Manx Maori Maori Marathi Marshallese Mongolian Nauru Navajo; Navaho Ndebele, North; North Ndebele Ndebele, South; South Ndebele Ndonga Nepali Northern Sami Norwegian Norwegian Nynorsk; Nynorsk, Norwegian Occitan (post 1500) Ojibwa Oriya Oromo Ossetian; Ossetic Pali Panjabi; Punjabi Persian Polish Portuguese Pushto; Pashto Quechua Romanian; Moldavian), Moldovan Romansh Rundi Russian Samoan Sango Sanskrit Sardinian Serbian Shona Sichuan Yi; Nuosu Sindhi Sinhala; Sinhalese Slovak Slovenian Somali Sotho, Southern Sundanese Swahili Swati Swedish Tagalog Tahitian Tajik Tamil Tatar Telugu Thai Tibetan Tigrinya Tonga (Tonga Islands) Tsonga Tswana Turkish Turkmen Twi Uighur; Uyghur Ukrainian Urdu Uzbek Venda Vietnamese Volap?k Walloon Welsh Western Frisian Wolof Xhosa Yiddish Yoruba Zhuang; Chuang Zulu Other
Ethnicity	Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Other

Currently pregnant or nursing

Yes No

Patient Ocular History

Patient Ocular Conditions (e.g. dry eyes, cataracts, floaters, glaucoma, macular degeneration etc.)

Ocular History (e.g. eye injuries, eye surgeries, retinal detachment etc.)

Eye Medications (e.g. prescription or over the counter eye drops)

Patient Medical History

Endocrine:	none diabetes neck pain other glands thyroid Other
If Diabetic:	YrDx A1c
Allergic/Immunologic:	none allergies Drug Allergies hay fever Lupus Sjogren's Other
Musculoskeletal:	none Arthritis Fibromyalgia Gout MS muscle/joint pain Osteoarthritis rheumatoid arthritis swollen joints Other
Cardiovascular:	none chest pain circulatory or vascular disease heart disease heart problems high blood pressure high cholesterol HTN stroke vascular disease Other
Constitutional(Current):	none fatigue fever other unexplained weight change Other
Ears, Nose, Throat:	none chronic cough dry mouth hearing loss laryngitis runny nose sinus congestion sinusitis Other
Gastrointestinal:	none Acid Reflux Celiac Disease Chrohns Disease Colitis IBS Ulcer Other
Genitourinary:	none kidney disease Prostrate Disease STD Other
Integumentary (Skin):	none Eczema excessive dryness Herpes Simplex Herpes Zoster itching Psoriasis rashes Rosacea Other
Lymphatic/Hematologic:	none anemia bleeding problems blood disorders ulcer Other
Neurological:	none alzheimer cerebral palsy dizziness epilepsy headaches migraines motion sickness multiple sclerosis numbness paralysis parkinsons seizures stroke tumor weakness Other
Psychiatric:	none ADHD anxiety bipolar depression special needs Other
Respiratory:	none asthma chronic bronchitis COPD coughing emphysema shortness of breath wheezing Other
Cancer:	none Other
Other:	none Other

Other Patient Medical Conditions

Medications - No current medications

Allergies - No known drug allergies

Family Ocular History

Glaucoma	None Mother Father Sibling Grandparent Other
Macular Degeneration	None Mother Father Sibling Grandparent Other
Retinal Detachment	None Mother Father Sibling Grandparent Other
Cataract	None Mother Father Sibling Grandparent Other
Amblyopia / Strabismus	None Mother Father Sibling Grandparent Other
Blindness	None Mother Father Sibling Grandparent Other

Other Family Ocular Conditions

Family Medical History

Diabetes	None Mother Father Sibling Grandparent Other
Hypertension	None Mother Father Sibling Grandparent Other
Thyroid	None Mother Father Sibling Grandparent Other

Heart Disease	None Mother Father Sibling Grandparent Other
Cancer	None Mother Father Sibling Grandparent Other

Other Family Medical Conditions - Family History Unknown

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