Online Patient Form
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Patient Information
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
City:
State:
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
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip Code:
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
Billing Information
Is The Billing Address The Same?
Yes
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
City:
State:
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
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip Code:
Home Phone:
Work Phone:
Primary
Insurance Information
Insurance Name:
None
3M/Hoya Safety Program
A R Benefits
AARP
AARP Medicare Advantage
AARP/Medicare Complete-United Healthcare
AC-UAW Retiree Trust
Advantage
Aetna US Healthcare
AFLAC
All Savers
All SaversAlternate Funding
Allied Benefit Systems, Inc.
Allied National-Globalcare, Inc.
American Continental Insurance Company
American Family Insurance Group
American Medical Security
American Pioneer
American Republic Insurance Company
American Retirement Life Insurance Company
AMS
Anthem Blue Cross Blue Shield
Apostrophe
APWU Health Plan
ASR Health Benefits
Associated Administrators, LLC
Assurant Health/ASA
Auditor of State of Indiana
AUDITOR OF STATE OF INDIANA
Automated Group Administration
AVMA Group Health and Life Insurance Trust
BAC
Bankers Fidelity
Bankers Life and Casualty Company
Bell-Duffens
Benefit Administrative Systems, LLC
Benemax
Benicomp, Inc.
CANNOT FILE
Care Improvement Plus
CareFirst
CareSource
CBA
Celtic Individual Health
Central States Funds
Central States Indemnity
Central United Life
ChampVA
Chesterfield Resources, Inc.
Choice Benefits
Cigna
Cigna Medicare Supplement Solutions
CNA
Cofinity
COLLECTION ASSOCIATES/RMP
Colonial Penn Life Insurance Company
Combined Insurance Company of America
Community Gold Plan
Community Health Network - Bronze
Community Silver Plan
Comprehensive Benefits
Conseco Life Insurance Company
Constitution Life Insurance Company
Continental General Insurance Company
Continental Life Insurance Company
Cook Group Health Plan Trust
Coventry Health Care
CRX Laboratories, LLC
CSI
Dean Health Plan
DMERC REGION B CEDI
Dunn and Associates
Electrical Workers Benefit Trust Fund Local 481
Employee Plans, LLC
Encore Health Network
Equitable National
ESIS
ESSILOR OF AMERICA
Everest
Eye Surgeons of Indiana
Eyeconic
Eyemed/ECPA Managed Care Claims
Family Life Insurance Company
Farm Bureau Health Plans
FlexMed / TCC of South Carolina
FMH Coresource
Forethought Life Insurance Company
Freedom Life Insurance Company of America
Freudenberg-NOK Safety
GEHA
Genworth Life and Annuity Insurance Company
Gerber Life Insurance Company
GHC - SWC
Golden Rule
GPA
GPM Health & Life Insurance Company
Great American Life Insurance Company
GRI
Group Marketing Services, Inc.
Guarantee Trust Life Insurance Company
GWH-Cigna
Hartford Life & Accident Insurance Company
Harvard Pilgrim Health Care
Health Design Plus, Inc.
Health Scope Benefits
HealthPartners Claims
Healthsmart Benefit Solutions Inc.
Heartland National Life Insurance Company
HMO-CANNOT FILE
HSA
Humana
IBEW
ICHIA
Indiana Laborers Welfare Fund
Indiana Teamster's Health Benefits Fund
Indiana Teamsters Health Benefits
Indiana University Health Plans - PORTLAND
Indiana University Health Plans - SCRANTON
Indiana/Kentucky Carpenters Welfare Fund
IPEP
Iron Workers Benefit Trust
IU Health Plans - COLUMBUS
J & J
JFP Benefit Management, Inc.
Kaiser Permanente National Claims Administration - Northwest
Keenan
Key Benefit Administrators, Inc
KSKI Life
Lasso Healthcare MSA
LHI
LHS/MedCost Solutions, LLC
Lumico
Maestro Health
Mail Handlers Benefit Plan
Managed Health Services
Manhattan Life Insurance Company
MECA
Med Ben
Medco
Medi Share
Medica
Medical Mutual of Ohio
Medicare of Indiana
Medico Insurance Company
Members Health Insurance Company
Meritain
Mid-Central Operating Engineers Health & Welfare
Monumental Life Insurance Company
Mutual of Omaha
NALC Health Benefit Plan
National Asbestos Workers Medical Fund
National Automatic Sprinkler Industry Welfare Fund
National Record Retrieval
Nippon Life Insurance Co Of America
No Insurance
NONE
North America Administrators, L. P.
Operating Engineers Health & Welfare Fund
PAI
Palmetto Gba
Pekin Life Insurance Company
Philadelphia American Life Insurance Company
Physicians Life Insurance Company
Physicians Mutual Insurance Company
Pipeline Industry Benefit Fund
Plumbers & Steamfitters Local #440 Health & Welfare Fund
Preferred Health Plan, Inc
Price Vision Group
Principal Life Insurance Co
Pro Health/HealthChoice
Professional Benefit Administrators, Inc
Refractive Management LLC
Reserve National Insurance Company
Rural Carrier Benefit Plan
Rural Carrier Benefit Plan
Sagamore
Secure Horizons
SecureOne Benefit Administrators, Inc.
Select Benefit Administrators
SIHO
Smart Health
Springhurst Health Campus
State Farm Health Insurance
STATE OF INDIANA
Strategic Comp
Teamsters 360 Sagamore Network
The Indiana State Council of Roofers Health & Welfare Fund
The J P Farley Corporation
The Mail Handlers Benefit Plan
The MEGA Life & Health Insurance Company
The Order of United Commercial Travelers of America
Thrivent Financial for Lutherans
TLC Indiana Laser Center, Inc.
Today's Options
Transamerica Premier Life Insurance Company
TREASURER OF HANCOCK CTY
Tricare
Tricare for Life
TUFTS Health Plan
UHCLIC
UHSS
UMR
UMWA Health and Retirement Funds
Unified Group Services, Inc.
Unified Life Insurance Company
Union Fidelity Life Insurance Company
United American Insurance Company
United Commercial Travelers of America
United Health Care
United Health Integrated Services
United of Omaha
United Teacher Associates Insurance Company
United World Life
US Health and Life Insurance Company
USAA Life Insurance Company
VA/Department of Veterans Affairs
Veterans Choice Program
Vision Service Plan
Washington National Insurance Company
WebTPA
Western & Southern Financial Group
World Insurance Company
XXXMISC
Your Choice Marketplace
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
3M/Hoya Safety Program
A R Benefits
AARP
AARP Medicare Advantage
AARP/Medicare Complete-United Healthcare
AC-UAW Retiree Trust
Advantage
Aetna US Healthcare
AFLAC
All Savers
All SaversAlternate Funding
Allied Benefit Systems, Inc.
Allied National-Globalcare, Inc.
American Continental Insurance Company
American Family Insurance Group
American Medical Security
American Pioneer
American Republic Insurance Company
American Retirement Life Insurance Company
AMS
Anthem Blue Cross Blue Shield
Apostrophe
APWU Health Plan
ASR Health Benefits
Associated Administrators, LLC
Assurant Health/ASA
Auditor of State of Indiana
AUDITOR OF STATE OF INDIANA
Automated Group Administration
AVMA Group Health and Life Insurance Trust
BAC
Bankers Fidelity
Bankers Life and Casualty Company
Bell-Duffens
Benefit Administrative Systems, LLC
Benemax
Benicomp, Inc.
CANNOT FILE
Care Improvement Plus
CareFirst
CareSource
CBA
Celtic Individual Health
Central States Funds
Central States Indemnity
Central United Life
ChampVA
Chesterfield Resources, Inc.
Choice Benefits
Cigna
Cigna Medicare Supplement Solutions
CNA
Cofinity
COLLECTION ASSOCIATES/RMP
Colonial Penn Life Insurance Company
Combined Insurance Company of America
Community Gold Plan
Community Health Network - Bronze
Community Silver Plan
Comprehensive Benefits
Conseco Life Insurance Company
Constitution Life Insurance Company
Continental General Insurance Company
Continental Life Insurance Company
Cook Group Health Plan Trust
Coventry Health Care
CRX Laboratories, LLC
CSI
Dean Health Plan
DMERC REGION B CEDI
Dunn and Associates
Electrical Workers Benefit Trust Fund Local 481
Employee Plans, LLC
Encore Health Network
Equitable National
ESIS
ESSILOR OF AMERICA
Everest
Eye Surgeons of Indiana
Eyeconic
Eyemed/ECPA Managed Care Claims
Family Life Insurance Company
Farm Bureau Health Plans
FlexMed / TCC of South Carolina
FMH Coresource
Forethought Life Insurance Company
Freedom Life Insurance Company of America
Freudenberg-NOK Safety
GEHA
Genworth Life and Annuity Insurance Company
Gerber Life Insurance Company
GHC - SWC
Golden Rule
GPA
GPM Health & Life Insurance Company
Great American Life Insurance Company
GRI
Group Marketing Services, Inc.
Guarantee Trust Life Insurance Company
GWH-Cigna
Hartford Life & Accident Insurance Company
Harvard Pilgrim Health Care
Health Design Plus, Inc.
Health Scope Benefits
HealthPartners Claims
Healthsmart Benefit Solutions Inc.
Heartland National Life Insurance Company
HMO-CANNOT FILE
HSA
Humana
IBEW
ICHIA
Indiana Laborers Welfare Fund
Indiana Teamster's Health Benefits Fund
Indiana Teamsters Health Benefits
Indiana University Health Plans - PORTLAND
Indiana University Health Plans - SCRANTON
Indiana/Kentucky Carpenters Welfare Fund
IPEP
Iron Workers Benefit Trust
IU Health Plans - COLUMBUS
J & J
JFP Benefit Management, Inc.
Kaiser Permanente National Claims Administration - Northwest
Keenan
Key Benefit Administrators, Inc
KSKI Life
Lasso Healthcare MSA
LHI
LHS/MedCost Solutions, LLC
Lumico
Maestro Health
Mail Handlers Benefit Plan
Managed Health Services
Manhattan Life Insurance Company
MECA
Med Ben
Medco
Medi Share
Medica
Medical Mutual of Ohio
Medicare of Indiana
Medico Insurance Company
Members Health Insurance Company
Meritain
Mid-Central Operating Engineers Health & Welfare
Monumental Life Insurance Company
Mutual of Omaha
NALC Health Benefit Plan
National Asbestos Workers Medical Fund
National Automatic Sprinkler Industry Welfare Fund
National Record Retrieval
Nippon Life Insurance Co Of America
No Insurance
NONE
North America Administrators, L. P.
Operating Engineers Health & Welfare Fund
PAI
Palmetto Gba
Pekin Life Insurance Company
Philadelphia American Life Insurance Company
Physicians Life Insurance Company
Physicians Mutual Insurance Company
Pipeline Industry Benefit Fund
Plumbers & Steamfitters Local #440 Health & Welfare Fund
Preferred Health Plan, Inc
Price Vision Group
Principal Life Insurance Co
Pro Health/HealthChoice
Professional Benefit Administrators, Inc
Refractive Management LLC
Reserve National Insurance Company
Rural Carrier Benefit Plan
Rural Carrier Benefit Plan
Sagamore
Secure Horizons
SecureOne Benefit Administrators, Inc.
Select Benefit Administrators
SIHO
Smart Health
Springhurst Health Campus
State Farm Health Insurance
STATE OF INDIANA
Strategic Comp
Teamsters 360 Sagamore Network
The Indiana State Council of Roofers Health & Welfare Fund
The J P Farley Corporation
The Mail Handlers Benefit Plan
The MEGA Life & Health Insurance Company
The Order of United Commercial Travelers of America
Thrivent Financial for Lutherans
TLC Indiana Laser Center, Inc.
Today's Options
Transamerica Premier Life Insurance Company
TREASURER OF HANCOCK CTY
Tricare
Tricare for Life
TUFTS Health Plan
UHCLIC
UHSS
UMR
UMWA Health and Retirement Funds
Unified Group Services, Inc.
Unified Life Insurance Company
Union Fidelity Life Insurance Company
United American Insurance Company
United Commercial Travelers of America
United Health Care
United Health Integrated Services
United of Omaha
United Teacher Associates Insurance Company
United World Life
US Health and Life Insurance Company
USAA Life Insurance Company
VA/Department of Veterans Affairs
Veterans Choice Program
Vision Service Plan
Washington National Insurance Company
WebTPA
Western & Southern Financial Group
World Insurance Company
XXXMISC
Your Choice Marketplace
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
3M/Hoya Safety Program
A R Benefits
AARP
AARP Medicare Advantage
AARP/Medicare Complete-United Healthcare
AC-UAW Retiree Trust
Advantage
Aetna US Healthcare
AFLAC
All Savers
All SaversAlternate Funding
Allied Benefit Systems, Inc.
Allied National-Globalcare, Inc.
American Continental Insurance Company
American Family Insurance Group
American Medical Security
American Pioneer
American Republic Insurance Company
American Retirement Life Insurance Company
AMS
Anthem Blue Cross Blue Shield
Apostrophe
APWU Health Plan
ASR Health Benefits
Associated Administrators, LLC
Assurant Health/ASA
Auditor of State of Indiana
AUDITOR OF STATE OF INDIANA
Automated Group Administration
AVMA Group Health and Life Insurance Trust
BAC
Bankers Fidelity
Bankers Life and Casualty Company
Bell-Duffens
Benefit Administrative Systems, LLC
Benemax
Benicomp, Inc.
CANNOT FILE
Care Improvement Plus
CareFirst
CareSource
CBA
Celtic Individual Health
Central States Funds
Central States Indemnity
Central United Life
ChampVA
Chesterfield Resources, Inc.
Choice Benefits
Cigna
Cigna Medicare Supplement Solutions
CNA
Cofinity
COLLECTION ASSOCIATES/RMP
Colonial Penn Life Insurance Company
Combined Insurance Company of America
Community Gold Plan
Community Health Network - Bronze
Community Silver Plan
Comprehensive Benefits
Conseco Life Insurance Company
Constitution Life Insurance Company
Continental General Insurance Company
Continental Life Insurance Company
Cook Group Health Plan Trust
Coventry Health Care
CRX Laboratories, LLC
CSI
Dean Health Plan
DMERC REGION B CEDI
Dunn and Associates
Electrical Workers Benefit Trust Fund Local 481
Employee Plans, LLC
Encore Health Network
Equitable National
ESIS
ESSILOR OF AMERICA
Everest
Eye Surgeons of Indiana
Eyeconic
Eyemed/ECPA Managed Care Claims
Family Life Insurance Company
Farm Bureau Health Plans
FlexMed / TCC of South Carolina
FMH Coresource
Forethought Life Insurance Company
Freedom Life Insurance Company of America
Freudenberg-NOK Safety
GEHA
Genworth Life and Annuity Insurance Company
Gerber Life Insurance Company
GHC - SWC
Golden Rule
GPA
GPM Health & Life Insurance Company
Great American Life Insurance Company
GRI
Group Marketing Services, Inc.
Guarantee Trust Life Insurance Company
GWH-Cigna
Hartford Life & Accident Insurance Company
Harvard Pilgrim Health Care
Health Design Plus, Inc.
Health Scope Benefits
HealthPartners Claims
Healthsmart Benefit Solutions Inc.
Heartland National Life Insurance Company
HMO-CANNOT FILE
HSA
Humana
IBEW
ICHIA
Indiana Laborers Welfare Fund
Indiana Teamster's Health Benefits Fund
Indiana Teamsters Health Benefits
Indiana University Health Plans - PORTLAND
Indiana University Health Plans - SCRANTON
Indiana/Kentucky Carpenters Welfare Fund
IPEP
Iron Workers Benefit Trust
IU Health Plans - COLUMBUS
J & J
JFP Benefit Management, Inc.
Kaiser Permanente National Claims Administration - Northwest
Keenan
Key Benefit Administrators, Inc
KSKI Life
Lasso Healthcare MSA
LHI
LHS/MedCost Solutions, LLC
Lumico
Maestro Health
Mail Handlers Benefit Plan
Managed Health Services
Manhattan Life Insurance Company
MECA
Med Ben
Medco
Medi Share
Medica
Medical Mutual of Ohio
Medicare of Indiana
Medico Insurance Company
Members Health Insurance Company
Meritain
Mid-Central Operating Engineers Health & Welfare
Monumental Life Insurance Company
Mutual of Omaha
NALC Health Benefit Plan
National Asbestos Workers Medical Fund
National Automatic Sprinkler Industry Welfare Fund
National Record Retrieval
Nippon Life Insurance Co Of America
No Insurance
NONE
North America Administrators, L. P.
Operating Engineers Health & Welfare Fund
PAI
Palmetto Gba
Pekin Life Insurance Company
Philadelphia American Life Insurance Company
Physicians Life Insurance Company
Physicians Mutual Insurance Company
Pipeline Industry Benefit Fund
Plumbers & Steamfitters Local #440 Health & Welfare Fund
Preferred Health Plan, Inc
Price Vision Group
Principal Life Insurance Co
Pro Health/HealthChoice
Professional Benefit Administrators, Inc
Refractive Management LLC
Reserve National Insurance Company
Rural Carrier Benefit Plan
Rural Carrier Benefit Plan
Sagamore
Secure Horizons
SecureOne Benefit Administrators, Inc.
Select Benefit Administrators
SIHO
Smart Health
Springhurst Health Campus
State Farm Health Insurance
STATE OF INDIANA
Strategic Comp
Teamsters 360 Sagamore Network
The Indiana State Council of Roofers Health & Welfare Fund
The J P Farley Corporation
The Mail Handlers Benefit Plan
The MEGA Life & Health Insurance Company
The Order of United Commercial Travelers of America
Thrivent Financial for Lutherans
TLC Indiana Laser Center, Inc.
Today's Options
Transamerica Premier Life Insurance Company
TREASURER OF HANCOCK CTY
Tricare
Tricare for Life
TUFTS Health Plan
UHCLIC
UHSS
UMR
UMWA Health and Retirement Funds
Unified Group Services, Inc.
Unified Life Insurance Company
Union Fidelity Life Insurance Company
United American Insurance Company
United Commercial Travelers of America
United Health Care
United Health Integrated Services
United of Omaha
United Teacher Associates Insurance Company
United World Life
US Health and Life Insurance Company
USAA Life Insurance Company
VA/Department of Veterans Affairs
Veterans Choice Program
Vision Service Plan
Washington National Insurance Company
WebTPA
Western & Southern Financial Group
World Insurance Company
XXXMISC
Your Choice Marketplace
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!
Eye History
Reason For Visit:
Secondary Reasons:
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
Have you had any eye surgeries? Please describe:
Last Eye Exam:
1 year
2 years
3 years
Other
Last Appointment Type
By Doctor:
Primary Vision Correction:
None
Prescription Glasses
Prescription Reading Glasses
Soft Contacts
Non-Prescription Reading Glasses
Other
Do you: Have back up glasses?
No
Yes
Other
Want new glasses?
No
Yes
Other
Contact Lens Wearers only
Type of contacts worn in the past:
Cleaner:
Disposal:
Wear Time:
Medical History
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:
Yes
No
Unsure
Other
PATIENT MEDICAL HISTORY: HAs, Arthritis, Asthma, Diabetes, HBP, Heart, Infl. Bowel Dz, Seizures, Thyroid
Good health
Arthritis
Asthma
Diabetes
HBP
Headaches
Heart Condition
HX Of Drug/Alcohol Abuse
Inflammatory Bowel Disease
Smoking
Seizure Disorder
Thyroid Disease
Preg "Now"
Nursing
Diagnosed As HIV+
Other
Diabetes
HBP
Heart disease
Cancer
Arthritis
Lupus
Kidney
Thyroid
Back Problems
Other
Athritis
Diabetes
HBP
Heart Disease
Cancer
Lupus
Kidney Disease
Thyroid Disease
Back Problems
Other
Diabetes
HBP
Heart Disease
Cancer
Arthritis
Lupus
Kidney
Thyroid
Back Problems
Other
Diabetes
HBP
Heart Disease
Cancer
Arthritis
Lupus
Kidney
Thyroid Disease
Back Problems
Other
Diabetes
HBP
Heart Disease
Cancer
Arthritis
Lupus
Kidney Disease
Thyroid
Back Problems
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
Cardiovascular 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
Alzheimer's 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
Parkinson's Disease
Brain 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)
Sjogren's 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
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
STD
None
Gonorrhea
Syphilis
Hepatitis
HIV
TB
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