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

		May we contact you?
Home Phone:		Yes No
Work Phone:		Yes No	Text Message OK?
Cell Phone:		Yes No	Yes No
Other Phone:		Yes No
Email		Yes No
Preferred Contact Method:		Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Never Married Married Divorced Annulled Domestic Partner Legally Separated Interlocutory Widowed Polygamous	Employer/School Name
Please list the names of those we may speak to concerning your appointment. If an individual is not listed, we will not release any information to anyone other than you.
Guardian

Referred By:

Doctor Insurance Friend/Family Website/Internet Yellow Pages Walk-by/Drive-by

Any Family Patients?:

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:

Medical

Insurance Information

Insurance Name:	None AARP AARP AARP United Healthcare Advantica Commercial Aetna Aetna Medicare Agilent Safety Glasses Fee Alamo Cement (Out of Network) Alaska Care Allied Always Vision/First Look American Retirement Ameriplan Ameritas Avesis Bastrop County Indigent Health Care Program Bastrop Lost Pines Lions Club BLUE CROSS BLUE SHEILD BMA Boon-Chapman Benefit Administrators Inc. CapRock Care Improvement Plus Cigna Coast to Coast Core Health Insurance DARS Disability Determination Services Davis Vision Davis Vision - City of Austin Davis Vision American National Insurance Davis Vision Bastrop County Davis Vision Guardian Davis Vision Shinetech Dental Select DETEX EYE BENEFITS EyeMed Eyemed Railroad Eyetopia First Health Network First Health/HIll Country MHMR GEHA Golden Rule Insurance Company GPA Hartford Health First TPA Health Smart Humana Humana Choice Humana Medicare Advantage Humana Vision Humana Vision-BISD LIFE RE Insurance Company Local 100 Loyal American Life Insurance Medicare Medicare Railroad MetLife MHBP Mutual of Omaha National Vision Administrators, L.L.C. New Era Life Insurance New Insurance No Insurance PHCS Physicians Mutual Principal Financial Group SAFEGUARD Scott and White Secondary Insurance after Medicare Sentinel Security Life Insurance Company Seton Healthcare (Out of Network) Sheet Metal Workers National Health Fund SPECTERA Superior Vision Texas True Choice The Chesapeake Insurance CO TML Intergovernmental Employee Benefits Pool TPA-Health First TRICARE TSO Vision Plan U of T at Austin UMR United Health Allies United Healthcare United HealthCare Vision Unity VSP VSP Choice VSP Signature Workmans Comp
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:

Vision

Insurance Information

Insurance Name:	None AARP AARP AARP United Healthcare Advantica Commercial Aetna Aetna Medicare Agilent Safety Glasses Fee Alamo Cement (Out of Network) Alaska Care Allied Always Vision/First Look American Retirement Ameriplan Ameritas Avesis Bastrop County Indigent Health Care Program Bastrop Lost Pines Lions Club BLUE CROSS BLUE SHEILD BMA Boon-Chapman Benefit Administrators Inc. CapRock Care Improvement Plus Cigna Coast to Coast Core Health Insurance DARS Disability Determination Services Davis Vision Davis Vision - City of Austin Davis Vision American National Insurance Davis Vision Bastrop County Davis Vision Guardian Davis Vision Shinetech Dental Select DETEX EYE BENEFITS EyeMed Eyemed Railroad Eyetopia First Health Network First Health/HIll Country MHMR GEHA Golden Rule Insurance Company GPA Hartford Health First TPA Health Smart Humana Humana Choice Humana Medicare Advantage Humana Vision Humana Vision-BISD LIFE RE Insurance Company Local 100 Loyal American Life Insurance Medicare Medicare Railroad MetLife MHBP Mutual of Omaha National Vision Administrators, L.L.C. New Era Life Insurance New Insurance No Insurance PHCS Physicians Mutual Principal Financial Group SAFEGUARD Scott and White Secondary Insurance after Medicare Sentinel Security Life Insurance Company Seton Healthcare (Out of Network) Sheet Metal Workers National Health Fund SPECTERA Superior Vision Texas True Choice The Chesapeake Insurance CO TML Intergovernmental Employee Benefits Pool TPA-Health First TRICARE TSO Vision Plan U of T at Austin UMR United Health Allies United Healthcare United HealthCare Vision Unity VSP VSP Choice VSP Signature Workmans Comp
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:

Supplemental

Insurance Information

Insurance Name:	None AARP AARP AARP United Healthcare Advantica Commercial Aetna Aetna Medicare Agilent Safety Glasses Fee Alamo Cement (Out of Network) Alaska Care Allied Always Vision/First Look American Retirement Ameriplan Ameritas Avesis Bastrop County Indigent Health Care Program Bastrop Lost Pines Lions Club BLUE CROSS BLUE SHEILD BMA Boon-Chapman Benefit Administrators Inc. CapRock Care Improvement Plus Cigna Coast to Coast Core Health Insurance DARS Disability Determination Services Davis Vision Davis Vision - City of Austin Davis Vision American National Insurance Davis Vision Bastrop County Davis Vision Guardian Davis Vision Shinetech Dental Select DETEX EYE BENEFITS EyeMed Eyemed Railroad Eyetopia First Health Network First Health/HIll Country MHMR GEHA Golden Rule Insurance Company GPA Hartford Health First TPA Health Smart Humana Humana Choice Humana Medicare Advantage Humana Vision Humana Vision-BISD LIFE RE Insurance Company Local 100 Loyal American Life Insurance Medicare Medicare Railroad MetLife MHBP Mutual of Omaha National Vision Administrators, L.L.C. New Era Life Insurance New Insurance No Insurance PHCS Physicians Mutual Principal Financial Group SAFEGUARD Scott and White Secondary Insurance after Medicare Sentinel Security Life Insurance Company Seton Healthcare (Out of Network) Sheet Metal Workers National Health Fund SPECTERA Superior Vision Texas True Choice The Chesapeake Insurance CO TML Intergovernmental Employee Benefits Pool TPA-Health First TRICARE TSO Vision Plan U of T at Austin UMR United Health Allies United Healthcare United HealthCare Vision Unity VSP VSP Choice VSP Signature Workmans Comp
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

Last Eye Exam		Last Eye Doctor:	Dr Solly Pearl Dr. Lens Crafter's Dr. Alexander M.D. Broberg M.D. Dell M.D. Eyemasters Howerton M.D. Henderson M.D. Jacobs O.D. Leslie M.D. McNabb M.D. Seargent M.D. Stearns O.D. Treadwell O.D. Walters M.D. Sorrenson, O.D. Hammond, O.D. Wasser, O.D. Target Dr. Wal-Mart Dr.
Primary Care Physician:	Dr Battle Dr. Blevins Dr Carroll Dr Cullen Dr Dougherty Dr. Goss Dr Porter Dr Gupta Dr Lerma Dr Levitan Dr Reddy Dr Sanchez Dr Schriender Dr Scumpia Dr Sherman Dr Biel Dr Fehrenkamp Dr Vocal Dr Chavez Dr Walkes Dr Tew Dr Young Dr Spears	Referring Doctor:

Primary Vision Correction:

Bifocals Contacts Contacts - Mono None Progressives Single Vision Trifocals

Own Sunglasses?

Yes No

Interested in Laser Vision Correction?

Yes No

Contact Lens Information
Interested In Contact Lenses?	Yes No
Ever Worn Contact Lenses?	Yes No
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
How often do you throw contacts away?	Daily Weekly Monthly Bi-Monthly Yearly
Do you sleep in your contacts?	Yes No
If so, how many days at a time?
Back-up glasses for contacts?	Yes No

Check all that apply

Personal Eye Health History
None
Dry	Pain	Infection	Blurred Vision
Iritis	Injury	Retina Disease	Cross or Lazy Eye
Itching	Watering	Squinting	Mucous Discharge
Flashes	Floaters	Double Vision	Glare/Light Sensitive
Burning	Fatigue	Redness	Halos around lights
Cataracts	Glaucoma	Corneal Disease	Surgery
Other:

Medications for the Eye:

None Acular Alphagan P 0.1% Alphagan P 0.15% Artificial Tears Azopt Betoptic-S .25% Betoptic .5% Betagan bimatoprost 0.03% brimonidine 0.15% brimonidine/timolol (Combigan) Combigan Cosopt Diamox Sequel 500 mg dorzolomide/timolol (Cosopt) Erythromycin FML FML Forte Gentamicin Lumigan 0.03% Neosporin Ocupress Patanol Pilo Gel Polytrim Pred Mild Pred Forte Propine Timoptic .25% Timoptic .5% Tobradex Travatan Trusopt 2% Voltaren Xalatan None

Family Member Eye Health History
None
Amblyopia	Blindness	Cataracts
Corneal Dystrophy	Glaucoma	Macular Degeneration
Retinal Detachment	Lazy Eye	Congenital Eye Disease:

---

Medical Health History
None
Constitutional:		Skin:
Fever	Weight Loss/Gain	Rosacea	Metal Allergies
Ear, Nose and Throat:		Respiratory:
Allergies	Sinus Infections	Asthma	Cronic Bronchitis
Hearing Loss		Emphysema	Tuberculosis
Vascular/Cardivascular:		COPD
High BP	Heart Disease	Gastrointestinal:
High Cholesterol	Stroke	Acid Reflux	Intestinal Problems
Endocrine:		Liver/Spleen problems
Thyroid	Other Glands	Genitourinary:
Diabetes		Genitals	Kidney
Glucose	Taken	Bladder
HA1C	Taken	Lymphatic/Hematologic
Bones, Joints and Muscles:		Anemia	Bleeding
Arthritis	Muscle/Joint Pain	Neurological:
Rheumatoid Arthritis		Headache	Seizures
Immune System:		Alzheimers	Parkinsons
Sickle Cell	Ulcer	Psychiatric Issues
HIV/AIDS
Other:
Pregnant	Nursing	Cancer	Type:
Prolonged Steroid Use
Exposed to or Infected with STD
Alcohol use	Daily Never Occasionally Rarely socially	Tobacco	Yes No smokeless
Illicit Drug Use	currenly in past	STD	Herpes Chlamydia Syphillis HIV HPV

All MEDICATIONS taken for any health condition (include Over-The-Counter and Birth Control):

No Prescription Medications being taken

Allergic Reactions
Drug Allergies:	Other Allergies:

No Known Drug Allergies

Your Family Members Medical History
None
Arthritis	Cancer	Diabetes I	Diabetes II
Hypertension	Hypercholesterolmia	Heart Disease

We want to know more about how you use your eyes:

Hobbies/Occupation
None
Arts and Crafts	Baseball	Basketball	Boating	Bowling
Cooking	Cycling	Dancing	Exercising	Fishing
Football	Golf	Gardening	Horses	Hunting
Jogging	Lawn Work	Outdoors	Painting	Photography
Piano	Ranching	Reading	Rodeo	Running
Sailing	Scuba	Sewing	Skiing	Soccer
Softball	Swimming	Tennis	T.V.	Video Games
Wake Boarding	Weights	Woodworking	Working on cars

NOTES/SOCIAL HISTORY

SIGNATURE PAGE

SIGNATURE AND CONSENT PAGE
*PAYMENT AGREEMENT (click to view) I authorize and request my insurance company to pay directly to the eye doctor or ophthalmic group insurance benefits otherwise payable to me. I understand that my eye care insurance carrier may pay less than the actual bill for services, therefore. I agree to be responsible for payment of the balance of all services rendered on my behalf or that of my dependents. I have the right to revoke this Authorization at any time by providing the practice with a signed written request. Until such a request is received the Authorization will be in effect for six years from the date of the most recent signed Authorization.
*NOTICE OF PRIVACY PRACTICES (click to view) You have the right to expect your personal health information to be protected as outlined in the Notice of Privacy Practices. The terms of the notice may change. If you desire, a copy of the new Notice will be provided to me by requesting one in writing from this practice. You can request to have your consent to use your Protected Health Information revoked at any time with a signed written request to this practice. By checking this box you agree that you have read and understand this form.
*OFFICE POLICIES (click to view) By checking this box, you are providing a signature on file for Bastrop Family Eye Care and acknowledge that you have read our office policies.