Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev. Fr. Miss Pastor

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:
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

Billing Information

Is The Billing Address Different?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Fr. Miss Pastor

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 History

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Medical History

Medical Conditions/Injuries:	Date:
Hypertension Elevated Cholesterol Diabetes Anxiety Depression Sleep Apnea Heart Murmur Stroke Heart Attack Prostate Herpes Thyroid Disease Cancer Asthma Insomnia Allergies Type 1 Diabetes Type 2 Diabetes Arthritis Parkinsons Epilepsy Seizures ADD / ADHD Acid Reflux Crohn's Disease Other
Hypertension Elevated Cholesterol Diabetes Anxiety Depression Sleep Apnea Heart Murmur Stroke Heart Attack Prostate Herpes Thyroid Disease Cancer Asthma Insomnia Allergies Type 1 Diabetes Type 2 Diabetes Arthritis Parkinsons Epilepsy Seizures ADD / ADHD Acid Reflex Crohn's Disease Other
Hypertension Elevated Cholesterol Diabetes Anxiety Depression Sleep Apnea Heart Murmur Stroke Heart Attack Prostate Herpes Thyroid Disease Cancer Asthma Insomnia Allergies Type 1 Diabetes Type 2 Diabetes Arthritis Parkinsons Epilepsy Seizures ADD / ADHD Acid Reflux Crohn's Disease Other
Hypertension Elevated Cholesterol Diabetes Anxiety Depression Sleep Apnea Heart Murmur Stroke Heart Attack Prostate Herpes Thyroid Disease Cancer Asthma Insomnia Allergies Type 1 Diabetes Type 2 Diabetes Arthritis Parkinsons Epilepsy Seizures ADD / ADHD Acid Reflux Crohn's Disease Other
Hypertension Elevated Cholesterol Diabetes Anxiety Depression Sleep Apnea Heart Murmur Stroke Heart Attack Prostate Herpes Thyroid Disease Cancer Asthma Insomnia Allergies Type 1 Diabetes Type 2 Diabetes Arthritis Parkinsons Epilepsy Seizures ADD / ADHD Acid Reflux Crohn's Disease Other
Hypertension Elevated Cholesterol Diabetes Anxiety Depression Sleep Apnea Heart Murmur Stroke Heart Attack Prostate Herpes Thyroid Disease Cancer Asthma Insomnia Allergies Type 1 Diabetes Type 2 Diabetes Arthritis Parkinsons Epilepsy Seizures ADD / ADHD Acid Reflux Crohn's Disease Other
Hypertension Elevated Cholesterol Diabetes Anxiety Depression Sleep Apnea Heart Murmur Stroke Heart Attack Prostate Herpes Thyroid Disease Cancer Asthma Insomnia Allergies Type 1 Diabetes Type 2 Diabetes Arthritis Parkinsons Epilepsy Seizures ADD / ADHD Acid Reflux Crohn's Disease Other
Hypertension Elevated Cholesterol Diabetes Anxiety Depression Sleep Apnea Heart Murmur Stroke Heart Attack Prostate Herpes Thyroid Disease Cancer Asthma Insomnia Allergies Type 1 Diabetes Type 2 Diabetes Arthritis Parkinsons Epilepsy Seizures ADD / ADHD Acid Reflux Crohn's Disease Other
Hypertension Elevated Cholesterol Diabetes Anxiety Depression Sleep Apnea Heart Murmur Stroke Heart Attack Prostate Herpes Thyroid Disease Cancer Asthma Insomnia Allergies Type 1 Diabetes Type 2 Diabetes Arthritis Parkinsons Epilepsy Seizures ADD / ADHD Crohn's Disease Acid Reflux Other
Hypertension Elevated Cholesterol Diabetes Anxiety Depression Sleep Apnea Heart Murmur Stroke Heart Attack Prostate Herpes Thyroid Disease Cancer Asthma Insomnia Allergies Type 1 Diabetes Type 2 Diabetes Arthritis Parkinsons Epilepsy Seizures ADD / ADHD Acid Reflux Crohn's Disease Other

Do you need your glasses prescriptions updated? Yes No Possibly

Height:

ft.

in.

Weight:

lbs.

Eye Medications:

Pregnant or Nursing:

Surgeries:	Date:

Prescription Medications (Including Dosage):

Allergies to Medications:

Over the Counter Meds/Vitamins:

Primary Care Physician:

Review of Systems

General:	None Fatigue Weight loss/gain Fever Chills Night Sweats Other (Fatigue, Weight loss/gain, fever, chills, night sweats)
Ear/Nose/Throat:	None Runny Nose Earaches Hearing Changes/loss/ringing Vertigo Sore Throat Other (Runny Nose, Ear aches, Hearing changes, Vertigo, Sore throat)
Cardiovascular:	None Chest Pain Palpitations Swelling of Feet Pain with Walking Other (Chest pain, Palpitations, Swelling of feet, Pain with walking)
Respiratory:	None Asthma Bronchitis Emphysema COPD Other (Asthma, Bronchitis, Emphysema, COPD)
Gastrointestinal:	None Abdominal pain Difficulty swallowing Change in bowel habits Other (Abdominal pain, Difficulty swallowing, Change in bowel habits)
Musculoskeletal:	None Joint pain/stiffness Joint swelling Joint redness/warmth Cramps Other (Joint pain/stiffness, swelling, reness/warmth, cramps)
Skin:	None Rash Hair loss Itching Pigmented lesions Other (Rash, Hair loss, Itching, Pigmented lesions)
Eyes:	None Sudden Blurred Vision Discharge Dryness Flashes/Floaters Loss of Vision Pain Other (Sudden Blurred vision, Dryness, Flashes/floaters , Loss of vision)
Neurological:	None Muscle weakness Memory loss Numbness Tingling Other (Muscle weakness, Memory loss, Numbness, Tingling)
Psychiatric:	None Anxiety Depression Hallucinations Nervousness Other (Anxiety, Depression, Hallucinations, Nervousness)
Endocrine:	None Heat/cold intolerance Excessive hunger Excessive thirst Excessive urination Other (Excessive Hunger, Excessive Thirst, Excessive Urination)
Genitourinary:	None painful urination frequent urination impotence yellow jaundice Other (Bladder infection, trouble urinating, incontinence)
Allergic/Immune:	None Swollen lymph nodes Itching/hives Hay fever Sneezing Other (Swollen Lymph Nodes, Itching/Hives, Hay Fever, Sneezing)
Other Symptoms:

Social History

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

Do you Exercise regularly?

Yes No Other

Do you drink?	No Yes Occasionally Socially Other	If yes, how much?	1 per wk 1 per/day 2 per/day 3+ per/day occasionally socially Other	Hobbies:

Ethnicity:

Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Other

Race:

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Patient Declined to Specify Other

Preferred Language:

English Spanish French Patient Declined to Specify Abkhazian Afar Afrikaans Akan Albanian Amharic Arabic Aragonese Armenian Assamese Avaric Avestan Aymara Azerbaijani Bambara Bashkir Basque Belarusian Bengali Bihari languages Bislama Bokm?l, Norwegian), Norwegian Bokm?l Bosnian Breton Bulgarian Burmese Catalan; Valencian Central Khmer Chamorro Chechen Chichewa; Chewa; Nyanja Chinese Church Slavic; Old Slavonic; Church Slavonic; Old Bulgarian; Old Church Slavonic Chuvash Cornish Corsican Cree Croatian Czech Danish Divehi; Dhivehi; Maldivian Dutch; Flemish Dzongkha Esperanto Estonian Ewe Faroese Fijian Finnish Fulah Gaelic; Scottish Gaelic Galician Ganda Georgian German Greek, Modern (1453-) Guarani Gujarati Haitian; Haitian Creole Hausa Hebrew Herero Hindi Hiri Motu Hungarian Icelandic Ido Igbo Indonesian Interlingua (International Auxiliary Language Association) Interlingue; Occidental Inuktitut Inupiaq Irish Italian Japanese Javanese Kalaallisut; Greenlandic Kannada Kanuri Kashmiri Kazakh Kikuyu; Gikuyu Kinyarwanda Kirghiz; Kyrgyz Komi Kongo Korean Kuanyama; Kwanyama Kurdish Lao Latin Latvian Limburgan; Limburger; Limburgish Lingala Lithuanian Luba-Katanga Luxembourgish; Letzeburgesch Macedonian Malagasy Malay Malay Malayalam Maltese Manx Maori Maori Marathi Marshallese Mongolian Nauru Navajo; Navaho Ndebele, North; North Ndebele Ndebele, South; South Ndebele Ndonga Nepali Northern Sami Norwegian Norwegian Nynorsk; Nynorsk, Norwegian Occitan (post 1500) Ojibwa Oriya Oromo Ossetian; Ossetic Pali Panjabi; Punjabi Persian Polish Portuguese Pushto; Pashto Quechua Romanian; Moldavian), Moldovan Romansh Rundi Russian Samoan Sango Sanskrit Sardinian Serbian Shona Sichuan Yi; Nuosu Sindhi Sinhala; Sinhalese Slovak Slovenian Somali Sotho, Southern Sundanese Swahili Swati Swedish Tagalog Tahitian Tajik Tamil Tatar Telugu Thai Tibetan Tigrinya Tonga (Tonga Islands) Tsonga Tswana Turkish Turkmen Twi Uighur; Uyghur Ukrainian Urdu Uzbek Venda Vietnamese Volap?k Walloon Welsh Western Frisian Wolof Xhosa Yiddish Yoruba Zhuang; Chuang Zulu Other

Family Medical History

Does your family have a history of these eye conditions? If so, which relative?

Unknown Family History

Lazy Eye:
Blindness:
Cataracts:
Color Blindness:
Glaucoma:
Mac Degen:
Retinal Detach:
Eye Turn:
Other:

Does your family have a history of these medical conditions? If so, which relative?

Arthritis:
Cancer:
Diabetes:
Heart Disease:
Blood Pressure:
Kidney Disease:
Lupus:
Stroke:
Thyroid:

Submit Data / Patient Signatures

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Notice of Privacy Practices

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Patient Signature: Date:

Billing Statement

Payment from my insurance is to be paid directly to Vision Health. I understand that billing my insurance company is a courtesy service that VH offers. I understand all benefits quoted to me are not a guarantee of payment by my insurance company and that final determination can only be made when the claim is processed. The undersigned will ultimately be responsible for any bill incurred in this office regardless of insurance.

Patient Signature: Date:

Vision Health Wellness Assessment

80 percent of everything we learn comes through our eyes, making eye health very important to your well-being and quality of life. Our doctors recommend our Wellness Assessment annually for all patients to assist in the early detection of eye and overall health conditions like glaucoma, macular degeneration, diabetes and high blood pressure.

The Wellness Assessment now includes two advanced, non-invasive retinal images that deliver an expanded, more detailed view of your internal eye not available in most other eye exams.

--Widefield imaging (Optos) captures a 200-degree image of the retina, assisting your doctor in detecting changes over time that can occur with common eye diseases and medical conditions.

--OCT (optical coherence tomography) imaging uses a non-contact beam of light to produce high-resolution, cross-sectional images of the eye's retina and optic nerve that enable your doctor to diagnose and manage eye conditions as well as ocular side-effects of certain medications.

Our doctors feel that these images are an extremely valuable addition to your comprehensive exam, and they recommend them for all our patients.

Our practice offers this advanced technology for $49, which is not covered by insurance plans.

Yes, I want to upgrade my comprehensive exam to the Wellness Assessment.
       *I acknowledge that the doctor may still recommend dilating my eyes if deemed necessary.
I'm not sure. I would like more information.
I will pass on the Wellness Assessment this year.
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