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:		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 Polygamous Widowed	Employer / School Name
Misc/Guardian

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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

Insurance Information

Insurance Name:	None Advantica Aetna ALTIUS AlwaysCare Blue Cross Blue Shield Cigna Cigna Vision Coventry Essilor EyeMed Humana HumanaVision Logistics Health Incorporated Medicare Health Insurance Meritain Health MSH International National Vision Administrators New Insurance North American Adminstrators, L.P. Olympus Managed Health Care OptiCare PHCS Prestige International USA, Inc. Spectera Eyecare Network Superior Vision TexanPlus HMO Tower Life Insurance Company UMR United Healthcare Vision Benefits of America Vision Service Plan: Access Plan Vision Service Plan: Choice Vision Service Plan: Signature
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 Advantica Aetna ALTIUS AlwaysCare Blue Cross Blue Shield Cigna Cigna Vision Coventry Essilor EyeMed Humana HumanaVision Logistics Health Incorporated Medicare Health Insurance Meritain Health MSH International National Vision Administrators New Insurance North American Adminstrators, L.P. Olympus Managed Health Care OptiCare PHCS Prestige International USA, Inc. Spectera Eyecare Network Superior Vision TexanPlus HMO Tower Life Insurance Company UMR United Healthcare Vision Benefits of America Vision Service Plan: Access Plan Vision Service Plan: Choice Vision Service Plan: Signature
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 Advantica Aetna ALTIUS AlwaysCare Blue Cross Blue Shield Cigna Cigna Vision Coventry Essilor EyeMed Humana HumanaVision Logistics Health Incorporated Medicare Health Insurance Meritain Health MSH International National Vision Administrators New Insurance North American Adminstrators, L.P. Olympus Managed Health Care OptiCare PHCS Prestige International USA, Inc. Spectera Eyecare Network Superior Vision TexanPlus HMO Tower Life Insurance Company UMR United Healthcare Vision Benefits of America Vision Service Plan: Access Plan Vision Service Plan: Choice Vision Service Plan: Signature
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!

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

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

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

Medical History

Patient Medical History:

Good health Arthritis Asthma HBP Headaches Heart Condition HX Of Drug/Alcohol Abuse Inflammatory Bowel Disease Smoking Seizure Disorder Thyroid Disease Preg "Now" Nursing Diagnosed As HIV+ Restless Leg Syndrome Cholesterol elevated Migraines Diabetes (Insulin) Diabetes (oral meds) Arthirits-Rheumatoid Arthritis-osteo Auto-immune Cancer Sjogrens Myasthenia Gravis Multiple Sclerosis Grave's Other	None Diabetes HBP Heart disease Cancer Arthritis Lupus Kidney Thyroid Back Problems Other	None Athritis Diabetes HBP Heart Disease Cancer Lupus Kidney Disease Thyroid Disease Back Problems Other
None Athritis Diabetes HBP Heart Disease Cancer Lupus Kidney Disease Thyroid Disease Back Problems Other	None Athritis Diabetes HBP Heart Disease Cancer Lupus Kidney Disease Thyroid Disease Back Problems Other	None Athritis Diabetes HBP Heart Disease Cancer Lupus Kidney Disease Thyroid Disease Back Problems Other

Systemic Meds:
None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Other	None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Other	None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Other	None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Other
None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Other	None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Other	None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Other	None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Other
None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Other	None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Other	None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Other	None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil Other

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

Family Medical History

Please select any conditions that apply to your family:

None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid Other

Review of Systems

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

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

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