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. Bereket Tsegai	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:

Primary

Insurance Information

Insurance Name:	None Aetna Better Health Aetna Medical AITHER HEALTH Allied Benefit System, Inc. Always Vision Amerigroup Medicaid Amerigroup Medicare Ameritas Anthem Health AS & G Avesis Vision Plan Blue Cross Blue Shield Care Credit Care Improvement Plus (Texas Dual Advantage) CHIP Cigna Health Springs Cigna Medical Cigna Vision -Healthy Rewards Discount Community Health Choice Davis Vision Devoted Health Envolve EYEMED First Health Heritage Vision Humana Medical Humana Military (Tricare) Kelsey-Seybold Clinic LIFESHIELD March Vision Medicare Medicare Advantage Memorial Herman Health Plan Meritain Health MES Vision Molina Medicaid MUTUAL OF OMAHA National Vision Administrators (NVA) Other Philadelphia American Life Insurance Physicians Mutual PHYSICIANS MUTUAL INS.CO Point Comfort Underwriters Premier Eye Care SB900 Blue Cross Blue Shield Spectera Superior Vision (PRIVATE) SUPERIOR VISION MEDICAID Texas Workforce Solutions Traditional TMHP Medicaid TRANSAMERICA PREMIER LIFE INS UMR United Healthcare Medical-Private United Healthcare Medical -Medicaid US Family health care Van Lang IPA Vision Benefits of America (VBA) Vision Service Plan WebTPA Wellcare
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 Aetna Better Health Aetna Medical AITHER HEALTH Allied Benefit System, Inc. Always Vision Amerigroup Medicaid Amerigroup Medicare Ameritas Anthem Health AS & G Avesis Vision Plan Blue Cross Blue Shield Care Credit Care Improvement Plus (Texas Dual Advantage) CHIP Cigna Health Springs Cigna Medical Cigna Vision -Healthy Rewards Discount Community Health Choice Davis Vision Devoted Health Envolve EYEMED First Health Heritage Vision Humana Medical Humana Military (Tricare) Kelsey-Seybold Clinic LIFESHIELD March Vision Medicare Medicare Advantage Memorial Herman Health Plan Meritain Health MES Vision Molina Medicaid MUTUAL OF OMAHA National Vision Administrators (NVA) Other Philadelphia American Life Insurance Physicians Mutual PHYSICIANS MUTUAL INS.CO Point Comfort Underwriters Premier Eye Care SB900 Blue Cross Blue Shield Spectera Superior Vision (PRIVATE) SUPERIOR VISION MEDICAID Texas Workforce Solutions Traditional TMHP Medicaid TRANSAMERICA PREMIER LIFE INS UMR United Healthcare Medical-Private United Healthcare Medical -Medicaid US Family health care Van Lang IPA Vision Benefits of America (VBA) Vision Service Plan WebTPA Wellcare
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 Aetna Better Health Aetna Medical AITHER HEALTH Allied Benefit System, Inc. Always Vision Amerigroup Medicaid Amerigroup Medicare Ameritas Anthem Health AS & G Avesis Vision Plan Blue Cross Blue Shield Care Credit Care Improvement Plus (Texas Dual Advantage) CHIP Cigna Health Springs Cigna Medical Cigna Vision -Healthy Rewards Discount Community Health Choice Davis Vision Devoted Health Envolve EYEMED First Health Heritage Vision Humana Medical Humana Military (Tricare) Kelsey-Seybold Clinic LIFESHIELD March Vision Medicare Medicare Advantage Memorial Herman Health Plan Meritain Health MES Vision Molina Medicaid MUTUAL OF OMAHA National Vision Administrators (NVA) Other Philadelphia American Life Insurance Physicians Mutual PHYSICIANS MUTUAL INS.CO Point Comfort Underwriters Premier Eye Care SB900 Blue Cross Blue Shield Spectera Superior Vision (PRIVATE) SUPERIOR VISION MEDICAID Texas Workforce Solutions Traditional TMHP Medicaid TRANSAMERICA PREMIER LIFE INS UMR United Healthcare Medical-Private United Healthcare Medical -Medicaid US Family health care Van Lang IPA Vision Benefits of America (VBA) Vision Service Plan WebTPA Wellcare
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

Referred By:

Referring Doctor:

Any family members patients here? Who?:

Hobbies:

Interested In Contact Lenses?

No Yes

Ever Worn Contact Lenses?

No Yes

Type of CLs worn in past:

Disposables Extended Wear Gas Permeables Gas Perm Bifocals Gas Perm Bitorics Gas Perm FS Toric Monovision - Soft Monovision - Disposables Monovision - Gas Perm No CL Hx Soft Daily Wear Soft Torics

Do you have back up glasses for your contacts?

Yes No

Primary Vision Correction:

None Bifocals Contacts Contacts - Mono Progressives Single Vision Trifocals

Sunglasses?

No Yes

Interested in Laser Vision Correction?

Not Interested Yes

Eye Hx: Sting, Burn, Itch, Surg.,Injury,Cats, Ambly.,Floaters, GL, Strab., Retinal

Blurred Vision None Pain in the eye Burning eye Itchy eye Red eye Abrasion Blind Eye Blepheroplasty Cataract - OU Cataract - OD Cataract - OS Conjunctivitis Glaucoma IOL - OU IOL - OD IOL - OS Metal in Eye Ptosis Retinal Detach Weak Eye Lazy Eye None

Eye Meds:

Last Eye Doctor:

Primary Care Physician:

Systemic Meds:

Med Hx: HAs,Arthritis,Asthma,Diabetes,HBP,Heart,Infl. Bowel Dz,Seizures,Thyroid,Smoke,Pregnant,Nursing,HIV+

Family Med History:

Family Eye History:

Medication and Seasonal Allergies:

NOTES/SOCIAL HISTORY

Review of Systems

DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?

General:  None Negative    Ears, Nose, Throat:  None dry mouth cough ear ache hard of hearing stuffy nose    Cardiovascular:  None High BP racing pulse


Respiratory:  None congestion short of breath wheezing Asthma Emphysema    Genital, Kidney, Bladder:  None frequent urination impotence painful urination yellow jaundice    Muscles, Bones, Joints:  None arthritis cramps joint pain stiffness swelling


Skin:  None growths pimples, warts rash Eczema    Neurological:  None headache numbness, paralysis seizures    Psychiatric:  None anxiety depression insomnia Retardation Down Syndrome


Endocrine:  None diabetes hypothyroid  :  Blood/Lymph:  None anemia bleeding cholestrolemia    Allergic/Immunologic:  None hives itching lupus redness sneezing swelling

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