Patient Information

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:
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. Soltys O.D., Robert Dr. Treadwell, Wilbur Dr. Elizondo O.D., Susan Dr. Haselhorst, Erik Dr. Sturm, Mark Dr. Summers, Karen Dr. Miller, Dina Dr. Smith, Brandon Dr. Tongoun, Erin Dr. Stephanie, Colorado Dr. Yee, Fern Dr. Barnett, Dr. Clay	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 AAA % AARP Aetna Ameritas Life Insurance Corp Bad Debt BCBS Collections Dental Select Express Eyes Eyemed Vision Care Family Discount Gift of Sight Health & Human Services (Only if Medicare Secondary) Humana Humana VCP LASER VIEW VISION CORRECTION Lens Crafters 2nd Opinion Fee Lenscrafters Discount Lumenos, Inc. Mailhandler's Benefit Plan Medicare Mutual of Omaha Other PHCS/MultiPlan - DO NOT TAKE AT THIS TIME PRINCIPAL LIFE INSURANCE CO. State Farm SUPERIOR VISION SERVICES Tricare UNICARE United Healthcare Vision Service Plan (VSP) Westlake Discount
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:
Employer/School:

Secondary

Insurance Information

Insurance Name:	None AAA % AARP Aetna Ameritas Life Insurance Corp Bad Debt BCBS Collections Dental Select Express Eyes Eyemed Vision Care Family Discount Gift of Sight Health & Human Services (Only if Medicare Secondary) Humana Humana VCP LASER VIEW VISION CORRECTION Lens Crafters 2nd Opinion Fee Lenscrafters Discount Lumenos, Inc. Mailhandler's Benefit Plan Medicare Mutual of Omaha Other PHCS/MultiPlan - DO NOT TAKE AT THIS TIME PRINCIPAL LIFE INSURANCE CO. State Farm SUPERIOR VISION SERVICES Tricare UNICARE United Healthcare Vision Service Plan (VSP) Westlake Discount
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:
Employer/School:

Tertiary

Insurance Information

Insurance Name:	None AAA % AARP Aetna Ameritas Life Insurance Corp Bad Debt BCBS Collections Dental Select Express Eyes Eyemed Vision Care Family Discount Gift of Sight Health & Human Services (Only if Medicare Secondary) Humana Humana VCP LASER VIEW VISION CORRECTION Lens Crafters 2nd Opinion Fee Lenscrafters Discount Lumenos, Inc. Mailhandler's Benefit Plan Medicare Mutual of Omaha Other PHCS/MultiPlan - DO NOT TAKE AT THIS TIME PRINCIPAL LIFE INSURANCE CO. State Farm SUPERIOR VISION SERVICES Tricare UNICARE United Healthcare Vision Service Plan (VSP) Westlake Discount
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:
Employer/School:

Medical History

How did you discover our practice?

Friend Family Yelp Internet Annual Postcard Other

Who was the last eye doctor you saw?

Doesn't Remember Never seen an Optometrist Dr.Soltys Dr.Elizondo Dr.Smith Other

Who is your Primary Care Physician:

Occupation:

Last Eye Examination:

Never 1 year 2 years 3 years Over 5 years Over 10 years

Systemic Meds:

None Allegra Allegra D Albuterol Alprazolam Ambien Amoxicillin Atenolol Avandia Birth Control Cephalexin Chlor-Trimeton Claritin Clonazepam Coumadin Fluoxetine Fosamax Furosemide Inderal Librax Lisinopril Muscle Relax Minipress Premarin Pamelor Plaquenil Reglan Relafen Sinequan SLO-BID Seldane Synthroid Seldane-D Thyroxine Toprol Verapamil Zantac Zetia Zocor Zoloft Zyrtec None Lipitor Hydrochlorothiazide Lexapro Metformin Synthroid Prednisone Nexium Singulair Prevacid Metoprolol Lorazepam Plavix Paroxetine Protonix Potassium Chloride Premarin Diovan Enalapril Diazepam Fluconazole Altace Wellbutrin XL Celebrex Viagra Doxycycline Lovastatin Allopurinol Clonidine Actos Pravachol Isosorbide Cozaar Glyburide Glucotrol Glipizide Tricor Coreg Lantus Mobic Flomax Crestor Ortho Tri-Cyclen Lo Temazepam Aciphex Spironolactone Xalatan Topomax Combivent Gemfibrozil Avapro Amaryl Trinessa Imitrex Acyclovir Propanolol Zyprexa Lamictal Aricept Depakote Buspirone Cialis Methotrexate Terazosin Avalide Quinine Humalog Lanoxin Paxil CR Digoxin Levothroid Nortriptyline Phenytoin Phentermine Biaxin Lunesta Prempro Spiriva Flovent Captopril Inderal LA Vigamox Hydroxychloroquine Baclofen Hydrocortisone Proscar Tobradex Lamisil Augmentin Flexeril Zithromax Norvasc

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

Family Med History:

None Diabetes HBP Cancer Adopted

Family Eye History (Glaucoma, RD, blindness):

None Adopted Cataracts Glaucoma Macular Degeneration Retinal Disorders

Allergies:

NKDA Codeine Environmental None PCN Seasonal Sulfa Drugs

Smoke?

No Yes Occaisional

Alcohol?

No Yes Social

Major Surgery or Illness

Hx of Eye Injury

Yes

Hx of Eye Disease

None Cataracts Glaucoma Retinal Detachment Diabetic Retinopathy Macular Degeneration

Hx of Eye Surgery

None Cataract SX Laser Surgery LASIK PK-Corneal Transplant

NOTES:

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