Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev. 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	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed	Employer / School Name
Misc/Guardian		Drivers License #

Is the Billing Address Different?

Billing Information

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

Copy Address From Above
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:

Vision

Insurance Information

Insurance Name:	None AARP (United Healthcare) ABA (Affordable Benefit Administrators) Aetna Always Care Anthem Blue Cross Avesis Block Vision Blue Shield of CA Cigna Clarity Vision Coastwise-ILWU/PMA Wlefare Plan Benefits Cole Vision Colonial Penn Davis Vision (Versant) Envolve Vision Essilor Eyemed Gerber Life Insurance Guardian Humana LHI March Vision Medi-Cal Medical Eye Services/MES Medicare Nippon Life Insurance Co. of America Opticare of Utah Oscar Risk Management Safeguard Significa Southern CA United Food & Commercial Workers Unions Spectera Superior Vision (Versant) Tricare for Life United HealthCare Vision Benefits of America/VBA Vision Plan of America/VPA Vision Service Plan/VSP
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

Insurance Information

Insurance Name:	None AARP (United Healthcare) ABA (Affordable Benefit Administrators) Aetna Always Care Anthem Blue Cross Avesis Block Vision Blue Shield of CA Cigna Clarity Vision Coastwise-ILWU/PMA Wlefare Plan Benefits Cole Vision Colonial Penn Davis Vision (Versant) Envolve Vision Essilor Eyemed Gerber Life Insurance Guardian Humana LHI March Vision Medi-Cal Medical Eye Services/MES Medicare Nippon Life Insurance Co. of America Opticare of Utah Oscar Risk Management Safeguard Significa Southern CA United Food & Commercial Workers Unions Spectera Superior Vision (Versant) Tricare for Life United HealthCare Vision Benefits of America/VBA Vision Plan of America/VPA Vision Service Plan/VSP
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

Referred By:

Referring Doctor:

Relatives that are Patients:

Occupation

Hobbies:

What is your primary vision correction?

None Single Vision Bifocals Trifocals Progressives Contacts Contacts - Mono Contacts - MF

Are you interested in contact lenses?

Yes No

How many hours/day do you work on the computer?

0-2 2-4 4-6 6-8 8+

What type of contacts do you wear?

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

Who is your primary care physician?

Who was your last eye doctor?

Dr. Robert Tamayo Dr. Linh Tu

What eye medication(s) do you currently use?

What systemic medication(s) do you currently use?

Please list any other pertinent medical history: Pregnant, Nursing, HIV+, other STDs

Do you have any allergies?

Please list other pertinent information: Smoking, Alcohol, Drug Use, Etc

Do you currently wear sunglasses?

Yes No

Do you have back-up glasses for your contacts?

Yes No

Are you interested in Laser Vision Correction/LASIK?

No Yes

Do you have any of the following medical conditions? Please select Yes or No.

Arthritis:

No Yes

Cancer:

No Yes

Diabetes:

No Yes

Heart Disease:

No Yes

High Blood Pressure:

No Yes

Thyroid Disease:

No Yes

Other:

None

Do you have any of the following ocular or eye conditions? Please select Yes or No.

Retinal Condition:

No Yes

Macular Degeneration:

No Yes

Glaucoma:

No Yes

Cataracts:

No Yes

Eye Injury/Surgery:

No Yes

Prominent Eyes:

No Yes

Flashes/Floaters:

No Yes

Headaches:

No Yes

Light Sensitivity:

No Yes

Itching/Burning:

No Yes

Excessive Tearing:

No Yes

Crossed Eyes:

No Yes

Discharge:

No Yes

Blindness:

No Yes

Double Vision:

No Yes

Loss of Vision:

No Yes

Blurry Vision:

No Yes

Other:

None

Does anyone in your family have any of the following eye or medical conditions?

Blindness

None Mother Father Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Maternal Aunty Maternal Uncle Paternal Aunty Paternal Uncle

Cataract

None Mother Father Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Maternal Aunty Maternal Uncle Paternal Aunty Paternal Uncle

Crossed Eye

None Mother Father Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Maternal Aunty Maternal Uncle Paternal Aunty Paternal Uncle

Glaucoma

None Mother Father Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Maternal Aunty Maternal Uncle Paternal Aunty Paternal Uncle

Macular Degeneration

None Mother Father Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Maternal Aunty Maternal Uncle Paternal Aunty Paternal Uncle

Retinal Detachment/Disease

None Mother Father Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Maternal Aunty Maternal Uncle Paternal Aunty Paternal Uncle

Arthritis

None Mother Father Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Maternal Aunty Maternal Uncle Paternal Aunty Paternal Uncle

Cancer

None Mother Father Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Maternal Aunty Maternal Uncle Paternal Aunty Paternal Uncle

Diabetes

None Mother Father Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Maternal Aunty Maternal Uncle Paternal Aunty Paternal Uncle

Heart Disease

None Mother Father Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Maternal Aunty Maternal Uncle Paternal Aunty Paternal Uncle

High Blood Pressure

None Mother Father Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Maternal Aunty Maternal Uncle Paternal Aunty Paternal Uncle

Kidney Disease

None Mother Father Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Maternal Aunty Maternal Uncle Paternal Aunty Paternal Uncle

Lupus

None Mother Father Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Maternal Aunty Maternal Uncle Paternal Aunty Paternal Uncle

Thyroid Disease

None Mother Father Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Maternal Aunty Maternal Uncle Paternal Aunty Paternal Uncle

Other

None Mother Father Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Maternal Aunty Maternal Uncle Paternal Aunty Paternal Uncle

Review of Systems

Do you have any of the following conditions? Please select from the drop down menu.

GENERAL: Fever, Weight loss, Weight gain, Fatigue

None Fever Weight gain Weight Loss

EAR, NOSE, MOUTH, THROAT: Allergies, Sinus, Cough, Dry Mouth/Throat

None Allergies Hay fever Sinus Problems Chronic Cough Dry Throat / Mouth Hard of Hearing Runny Nose Post-nasal drip

CARDIOVASCULAR: Hypertension, Heart Surgery, Vascular Disease

None Surgery Vascular Disease Hypertension Heart Disease Diabetes High Cholesterol

RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD

None Asthma Bronchitis Emphysema COPD

GENITOURINARY: Kidney Stones, Frequent Urination, Impotence, BPH

None Painful urination Frequent urination Impotence BPH Kidney stones

MUSCULOSKELETAL: Athritis, Joint Pain, Head or Neck Injury

None Arthritis Joint pain Muscle pain Stiffness Swelling Cramps Osteoporosis Osteopenia

INTEGUMENTARY: Growths, Rashes, Acne

None Growths Rash Acne Warts

NEUROLOGICAL: Headaches, Migraines, Seizures

None Numbness, paralysis Headache Seizures Migraines Multiple sclerosis

PSYCHIATRIC: Depression, Anxiety, Insomnia

None Anxiety Depression Insomnia ADD ADHD Bi-polar disorder

ENDOCRINE: Thyroid, Diabetes

None Hypothyroid Hyperthyroid Diabetes

HEMATOLOGIC/LYMPHATIC: Anemia, Bleeding problems

None Bleeding Anemia

ALLERGIC/IMMUNOLOGIC: Seasonal Allergies, Allergy Shots

None Sneezing Swelling Redness Itching HIV Hives Lupus Lyme Disease Sarcoidosis Guillain-Barr? syndrome

GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

None Diarrhea Constipation Ulcer Acid Reflux Irritable bowel syndrome

Social History

Smoking Status

Never smoker (<100 lifetime cigarettes or equivalent quantity of cigar or pipe smoke) Former smoker (no longer smokes)">Former smoker (no longer smokes)">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) Smoker (current status unknown) Unknown if ever smoked Other

Preferred Language

English Spanish 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

Ethnicity

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

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