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	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Widowed	Employer / School Name
Misc/Guardian

Parent/Guardian Information

Billing Information

Address Same As Above

Title	First	Last	MI	Suffix
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:

Primary

Insurance Information

Insurance Name:	None A-G Administrators A A R P Aetna Allwell Medicare Ambetter of Arkansas AR Medicaid Arkansas Virtual Academy Avesis Blue Cross Blue Shield BMI-Health Plans Boon Chapman Champva Cherokee Nation Chickasaw Nation Choctaw Nation of Oklahoma Choice Benefits Christian Brothers Employee Benefit Trus Cigna Empower Healthcare Solutions LLC Eye Med Golden Rule HealthChoice Humana Medicare Medipak Meritain Health Municipal Health Benefit Fund Mutual of Omaha Novasys Oklahoma Medicaid OLD SURETY LIFE INS CO Palmetto GBA Qualchoice of Arkansas Rural Carrier Benefit Plan Sentinel Security Life Spectera Summit Community Care Superior Vision Services Tricare East Regions Claim Dept. UAFS Athletic Dept. UMR Medical Insurance Union Pacific RR Emp Health Systems United Health Care Vision Service Plan Other
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

Insurance Information

Insurance Name:	None A-G Administrators A A R P Aetna Allwell Medicare Ambetter of Arkansas AR Medicaid Arkansas Virtual Academy Avesis Blue Cross Blue Shield BMI-Health Plans Boon Chapman Champva Cherokee Nation Chickasaw Nation Choctaw Nation of Oklahoma Choice Benefits Christian Brothers Employee Benefit Trus Cigna Empower Healthcare Solutions LLC Eye Med Golden Rule HealthChoice Humana Medicare Medipak Meritain Health Municipal Health Benefit Fund Mutual of Omaha Novasys Oklahoma Medicaid OLD SURETY LIFE INS CO Palmetto GBA Qualchoice of Arkansas Rural Carrier Benefit Plan Sentinel Security Life Spectera Summit Community Care Superior Vision Services Tricare East Regions Claim Dept. UAFS Athletic Dept. UMR Medical Insurance Union Pacific RR Emp Health Systems United Health Care Vision Service Plan Other
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:

Tertiary

Insurance Information

Insurance Name:	None A-G Administrators A A R P Aetna Allwell Medicare Ambetter of Arkansas AR Medicaid Arkansas Virtual Academy Avesis Blue Cross Blue Shield BMI-Health Plans Boon Chapman Champva Cherokee Nation Chickasaw Nation Choctaw Nation of Oklahoma Choice Benefits Christian Brothers Employee Benefit Trus Cigna Empower Healthcare Solutions LLC Eye Med Golden Rule HealthChoice Humana Medicare Medipak Meritain Health Municipal Health Benefit Fund Mutual of Omaha Novasys Oklahoma Medicaid OLD SURETY LIFE INS CO Palmetto GBA Qualchoice of Arkansas Rural Carrier Benefit Plan Sentinel Security Life Spectera Summit Community Care Superior Vision Services Tricare East Regions Claim Dept. UAFS Athletic Dept. UMR Medical Insurance Union Pacific RR Emp Health Systems United Health Care Vision Service Plan Other
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:

Chief Complaints

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:

Eye History

Do you currently have any of these symptoms?:	None Itching Burning, Stinging Red Floaters Flashes Of Light Eye Injuries Eye Surgery Amblyopia Strabismus Cataracts Glaucoma Retinal Disorders 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

List any ocular injuries:

Have you had any eye surgeries? Please describe:

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 glasses?

No Yes Other

Wear time:

Sunwear prescribed?

No Yes Other

Other optical devices:

Contact Lens Wearers only

Type of contacts worn in the past:		Wear time:
Contact Lens replacement schedule:
Do you sleep in your contacts?	Yes No	How often?

Contact lens brand:

Solution:

Current supply:

How many contact do you have left?

Do you need to order updated supply of contacts?

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	Blindness:	No Parents Siblings Grandparent Other
Myopia/Nearsighted:	No Parents Siblings Grandparent Other	Eye turn/Strabismus:	No Parents Siblings Grandparent Other	Other eye conditions:	No Parents Siblings Grandparent Other

Medical History

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Patient Medical History

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

Recent Flu Immunization:

Do you have any of these medical conditions? If yes, please describe:

None High Blood Pressure High Cholesterol Loss of Appetite Thyroid Heart Disease Cancer Stroke ADD/ADHD Autism Down Syndrome Other

Other medical history:(Ear infections, high fevers, ect)

Diabetes:

Year Diagnosed:

Glucometry:

A1C:

Family Medical History

Unknown family history

Does anyone in your family have any of these medical conditions?

None High Blood Pressure High Cholesterol Loss of Appetite Thyroid Heart Disease Cancer Stroke ADD/ADHD Autism Down Syndrome Other

Diabetes:

Year Diagnosed:

Glucometry:

A1C:

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

Review of Systems

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

General:	None Fatigue Fever Loss of Appetite Weight Gain Weight Loss Developmental Disorders Other	Ear/Nose/Throat:	None Neck Problems Sinus Problems Sore Throat (Recent) Headache Morning Headaches Migraine Headache Cluster Headache Hearing Loss Tinnitus Congestion Dry throat / mouth Sleep Apnea Other
Skin:	None Acne Lupus Dermatitis Eczema Psoriasis Rosacea Skin Cancer Itching Other	Cardiovascular:	None Congestive Heart Disease Cardivascular Disease High Cholesterol Hypertension Arrhythmia Heart Murmur Heart Palpitation Chest Pain Arteriosclerosis Coagulation Disorder Mitral Valve Prolapse Low Blood Pressure Other
Respiratory:	None Asthma Cancer: lung Sleep Apnea Sarcoidosis COPD Emphysema Pneumonia Bronchitis Shortness of breath Wheezing Other	Musculoskeletal:	None Arthritis Osteoporosis Fibromyalgia Osteoarthritis Muscular Dystrophy Lupus Decreased range of motion Muscle cramps Pain/tenderness Stiffness Swelling Weakness Other
Psychiatric:	None Attention Deficit Disorder Anxiety Brain Damage (trauma) Panic Attacks Alzheimers Disease Bi-polar Depression Insomnia Obsessive/Compulsive Paranoia Suicidal Violence Other	Gastrointestinal:	None Acid Reflux Crohn's disease Gastric reflux (GERD) IBS Ulcer Gall bladder problems Jaundice Hepatitis Sarcoidosis Cancer: colon Cancer: Liver Other
Endocrine:	None Crohn's disease Diabetes Type 1 Diabetes Type 2 Diabetes Suspect Hypothyroid Hyperthoyroid Gout Hormone Replacement Therapy Other	Blood/Lymph:	None Anemia Hx of Significant Blood Loss Hematologic Disorder Sickle Cell Disorder Breast Carcinoma Lymph Node Disease Temporal Arthritis Cuts slow to clot Easy bruising Other
Neurological:	None Multiple Sclerosis Seizure Disorder Parkinsons Disease Brian Tumor Bells Palsy Dyslexia Headache Balance problems Vertigo Tremors Changes in senses Dementia Memory problems Muscle weakness Numbness, paralysis Personality changes Speech problems Other	Genitourinary:	None Amenorrhea Menopause Impotence Jaundice Uterine Cancer Prostate Cancer Kidney Stones Pregnant Nursing Syphilis Prostate Problems Bladder Infections STD- herpetic STD- chlamydia Other
Immune:	None Seasonal allergies Environmental allergies Food allergies Drug allergies (please specify) Sjogrens syndrome AIDS Herpes Simplex HIV Simplex Mononucleosis Tuberculosis Cytomegalovirus Infection Herpes Zoster Lyme Disease Sarcoidosis Syphilis Hives Itching Mild allergy symptoms Severe allergy symptoms Swelling Other

Pediatric Developmental History

**This tab is only to be filled out for children 17 and under. Please fill out in addition to the other tabs**

Social/Other Information

Parent/Guardian Name:

Hobbies or sports:

Patient able to drive?

Yes No

Have visual difficulty driving?

Yes No

Have problems with night vision?

Yes No

Work on a computer?

Yes No

Hours per day?

Birth/Pregnancy History

Delivery was:

Normal C Section

Your child was delivered:

On time Early Late

Was vacuum or forceps used during pregnancy?

Yes No

Where there problems during pregnancy?

Yes No

During delivery?

Yes No

During labor?

Yes No

Immediately following birth?

Yes No

If yes please explain:

Birth weight:

Pounds

Ounces

Apgar score(If known)

Developmental History

Meeting/met developmental milestones?

Yes No

Please explain:

Crawled by (age):

Walked by (age):

Handed:

Has your child ever had the following testing and/or therapy?:

	Testing	When	Therapy
Educational	Yes No		Yes No
Occupational	Yes No		Yes No
Physical	Yes No		Yes No
Speech/Auditory	Yes No		Yes No
Neurological	Yes No		Yes No
Pychological	Yes No		Yes No
Medical special testing	Yes No		Yes No

Is the patient currently receiving therapies?

School Information

Name of childs school:

Grade

1. Date entered kindergarten:	Month:	Year:	Age:
Date entered first grade:	Month:	Year:	Age:

2. Does your child enjoy school? Yes No

Does your child like his/her teacher? Yes No

Is school attendance regular? Yes No

Please explain:

3. Has your child ever repeated any grade? Yes No

Grade:

4. In your opinion, what is your child's favorite school subject?

Easiest subject?

Hardest subject?

5.Has your child had any remedial work? Yes No

If yes, when?

In what subject?

From whom?

6. Has your child changed schools or teachers?

If yes, how often?

When and why?

7. Is your child receiviing any special educational services? Yes No

If yes, what is the service?

Myopia (Nearsighted)

Are the parents myopic/nearsighted? No One parent Both parents

Parent1 Prescription
Parent 2 Prescription

Patient race, Race is a factor in which plays a role as a risk factor in myopia devlopment:

How much near work(Anything within arm's reach, including any screens) does the patient do?

Less than 2 hours/day 2-4 hours/day More than 4 hours/day

Schooling of patient?

Private Public Charter Home Other

Outdoor time per day? Not including orgnized sport:

Less than 1 hour/day 1-2 hours/day More than 2 hours/day

Is the patient engaged in an organized sport?

Winer?	Yes No	Spring?	Yes No
Summer?	Yes No	Fall?	Yes No

Onset of myopia?

6-9yo 9-12yo 12-15yo 15-17yo 17+yo

Age of first correction for myopia (glasses or contacts)

Less than 6yo 6-9yo 9-12yo 12-15yo 15-17yo 17+ yo

Have you ever tried methods of myopia control in the past?

Glasses Bifocal glasses Bifocal/Multifocal contact lenses Antropine eye drops Otho Keratology Other

Finish