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	Single Married Widowed Divorced Separated	Employer / School Name
Spouse/Guardian		Do you have the following?:	Living Will Power of Attorney

Medical Insurance

Primary Medical Insurance Information

Insurance Name:	None AARP Aetna Aflac AmeriBen American Continental American Healthcare Alliance American Republic Insurance Comapany Amerigroup Community Care Assurant Auto Owners Beech Street Corp Bankers Life and Casualty Co Blue Cross Blue Shield Board Of Pensions Cahaba Medicare Champva Cigna Convenant Administrators, Inc. Family Care Health Plan Farm Bureau Gilsbar GTL Golden Rule Insurance Company GWH-CIGNA Healthscope HealthSpring Humana Liberty Mutual Workers comp Mail Handlers Benefit Plan Manhattan Life Manhattan Life Insurance Company MedCost Medicare Meritain Health MetLife Mutual of Omaha National Association of Letter Carriers OTHER Oxford Palmetto GBA PHCS Philadelphia American Life QMB Medicaid Bureau of TennCare Signature Health Alliance Smart Health Standard Life Insurance Company State Farm Health Insurance The Tennessee Plan TriCare South Region TriWest UMR United Health Care United Healthcare Community Plan United Teacher Associates Vocational Rehabilitation
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
Birthday:
Employer/School:

Secondary Medical Insurance Information

Insurance Name:	None AARP Aetna Aflac AmeriBen American Continental American Healthcare Alliance American Republic Insurance Comapany Amerigroup Community Care Assurant Auto Owners Beech Street Corp Bankers Life and Casualty Co Blue Cross Blue Shield Board Of Pensions Cahaba Medicare Champva Cigna Convenant Administrators, Inc. Family Care Health Plan Farm Bureau Gilsbar GTL Golden Rule Insurance Company GWH-CIGNA Healthscope HealthSpring Humana Liberty Mutual Workers comp Mail Handlers Benefit Plan Manhattan Life Manhattan Life Insurance Company MedCost Medicare Meritain Health MetLife Mutual of Omaha National Association of Letter Carriers OTHER Oxford Palmetto GBA PHCS Philadelphia American Life QMB Medicaid Bureau of TennCare Signature Health Alliance Smart Health Standard Life Insurance Company State Farm Health Insurance The Tennessee Plan TriCare South Region TriWest UMR United Health Care United Healthcare Community Plan United Teacher Associates Vocational Rehabilitation
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
Birthday:
Employer/School:

Please present your insurance card at the time of your appointment. If your medical insurance is not listed, please contact the office at least 5 business days prior to your first appointment.

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:

Medications: No Meds Used

Please describe any injuries or surgeries you have had:

Over The Counter Medications:

Vitamins:	Drug Allergies: No Known Drug Allergies

Primary Care Physician:

Pregnant Or Nursing:

No Yes Unsure Other

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

	Yes	No
Blurry Vision
Fluctuating Vision
Vision Loss
Distorted Vision
Double Vision
Squinting
Light Sentistive
Dry Eyes
Itchy Eyes
Burning Eye
Gritty/Sandy Eyes

	Yes	No
Flashing Lights
Floaters
Eye Pain
Eye Redness
Headaches
Reading Difficulties
Ocular Fatigue
Balance Difficulty
Frequent Falls
Bumping into Objects

Family Medical History

Unknown family history

Does anyone in your family have any of these medical conditions? If yes, please describe:

	Parent	Sibling	Other	None
Glaucoma
Macular Degen
Retinal Detach
Poor Vision
Cross/Lazy Eye
Diabetes
Hypertension
Heart Disease
Stroke
Cancer

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 Hyperthyroid 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	Eyes:	None Itching Burning, Stinging Red Floaters Flashes Of Light Eye Injuries Eye Surgery Amblyopia Strabismus Cataracts Glaucoma Retinal Disorders Other
Developmental	none unknown complicated birth medical complications Other	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
Alcohol Use:	No Yes Occasionally Socially Other
Illegal Drug Use:	No Yes Other

Race:

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Decline to Specify

Ethnicity:

African American Asian Caucasian Hispanic or Latino Other Pacific Islander Decline to Specify

Preferred Language:

English Spanish French Japanese Vietnamese Decline to Specify

Authorized Users - Name, Relationship, Phone, Notes