Online Patient Form

Demographics

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 Domestic Partner Separated Divorced Widowed Unknown	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Coon, Lynn	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
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:

Vision Insurance

If you have vision insurance, please fill out the Primary Vision Insurance section. If you have multiple vision insurances, please fill out Secondary, and Tertiary if needed.

Primary Vision Insurance

Insurance Name:	None New Insurance AARP AARP Medicare Complete Aetna Aetna AK Carpenters Alaska Electrical Health Fund Alaska Laborers H&S Fund Alaska National Insurance Alaska Pipe Trades Alaska Teamsters-Employer Welfare Trust Alaska UFCW Trust Allied Benefit Systems, LLC Allstate Insurance CAS CHAMPVA CIGNA Cigna Medicare Supplement Solutions Cigna PPO First Health Services Corp GEHA GEHA-ASA Humana Claims Dept Kenai Peninsula Borough School Medicare Meritain Meritain Health Moda Mutual Of Omaha Operating Engineers Premera State Farm Health Insurance Tricare For Life Tricare West Region Claims Department TriWest VA CCN Claims UHSS UMR United Services Automobile Association Claims Department UnitedHealth Integrated Services/ GEHA UnitedHealthcare VAPC3/Triwest Veterans Administration
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

If you have medical insurance, please fill out the Primary Medical Insurance section. If you have multiple medical insurances, please fill out Secondary and Tertiary if needed.

Primary Medical Insurance

Insurance Name:	None New Insurance AARP AARP Medicare Complete Aetna AK Carpenters Alaska Electrical Health Fund Alaska Laborers H&S Fund Alaska National Insurance Alaska Pipe Trades Alaska Teamsters-Employer Welfare Trust Alaska UFCW Trust Allied Benefit Systems, LLC Allstate Insurance CAS CHAMPVA CIGNA Cigna Medicare Supplement Solutions Cigna PPO First Health Services Corp GEHA GEHA-ASA Humana Claims Dept Kenai Peninsula Borough School Medicare Meritain Meritain Health Moda Mutual Of Omaha Operating Engineers Premera State Farm Health Insurance Tricare For Life Tricare West Region Claims Department TriWest VA CCN Claims UHSS UMR United Services Automobile Association Claims Department UnitedHealth Integrated Services/ GEHA UnitedHealthcare VAPC3/Triwest Veterans Administration
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:

Chief Complaint

Reason for Visit:

Location:	None Both Right Left Eyelids R Eyelids L Brow Behind Eyes Surface of Eyes Head Side of Head R Side of Head L Neck Forehead Face Shoulder R Shoulder L Other	Severity:	Dull Extreme Intense Mild Moderate Severe Sharp Totally Disabling 1/10 2/10 3/10 4/10 5/10 6/10 7/10 8/10 9/10 10/10 Other	Quality:	None Ache Better Black Spots Blur Burn Constant Discharge Distortion Double Vision Dry FB sensation Flashes Floaters Fuzzy Glare Gray, Dark Halos Haze Headache Hurt Itch Lump No Change Pain Puffy Redness Scratchy Sticky Sting Swollen Throbbing Tired Veil, Curtain Wavy Weepy, Tearing Worse Yellow Other	Duration:	None 1 day 2 days 3 days 4 days 5 days 6 days 1 week 1 month 3 months 6 months 1 year Rarely Once Always Gradually Other
Timing:	Never Always Comes & goes Constantly During the Day Infrequently Last night On rising Sometimes Suddenly This afternoon This morning Today Yesterday In the morning At night Other	Context:	At home At school At work Computer Dim lighting Distance Driving During hobbies During sports Focussing From dark to light From light to dark In bright light In low light Near None Oncoming headlights Outside Reading When looking down When looking left When looking right When looking up When tired With eyes closed Other	Modifying:	Adjusting distance of material Blinking Doctor's orders Drops help Glasses help Glasses worsen Hospitalization Light sensitive Moving closer Moving farther away None Oral meds help Other disease Other injury Previous episode Prior treatment helpful Prior treatment worsened Rubbing eyes Rx drops help Sleeping Squinting Surgery Systemic diseases Tears help Temperature Trauma Working Worse in AM Worse in PM Worse with blinking Worse with eye movement Other	Associated:	None Bleeding Blurred vision Cloudy Discharge Dizzy Elevated Pressure Eye pain Feels warm or hot Fright Headache Loss of Vision Pain Puffy Redness Swelling Twitch Unconscious Vomiting Other

Secondary Reasons:

Do you have a history of eye problems?:

Any eye injuries, head trauma, eye trauma or eye surgeries since last visit?

None Yes Other

Do you take any eye medications?:

Last Eye Exam:

By Doctor:

Doesn't Remember Never Coon Erickson Porter Other

Primary Vision Correction:

None Glasses-Full Time Glasses-Readers Only Contacts - Soft RGPs PMMA Low Vision Aid Other

Do you have backup glasses?	Yes No Other
Planning to get new glasses?	Yes No Other

If you wear contacts, which ones?:

None Acuvue 1-Day Define Acuvue 1 Day Moist Acuvue 2 Acuvue 2 Colors Acuvue Advance Acuvue Advance Plus Acuvue Bifocal Acuvue Oasys Advance Toric Air Optix Air Optix Aqua N&D Air Optix Multifocal Air Optix Toric Aqua Clear Aqua Clear 100 Aqua Clear 100 Toric Aqua Clear Toric Avaira Avaira Toric B&L ULTRA Biofinity Biofinity Multifocal Biofinity Toric Biomedics 55 Biomedics 55 Premium Biomedics Toric Biomedics XC BioTrue ONEday BioTrue ONEday Multifocal Boston ES Boston II Boston IV Boston XO Clariti 1-Day Daily Totals 1 DT 1 F 55 Toric Focus Dailies Focus Dailies Toric Freq 55 Freq 55 Aspheric Freshlook Colors Freshlook VT Oasys Multifocal Oasys Toric Paragon HDS Paragon Thin Polycon II Proclear ProClear Multifocal ProClear Multifocal Toric ProClear toric ProClear Toric XR PureVision PureVision Toric PureVision Toric PureVsion 2 HD Rose K Sauflon Soflens 38 Soflens 66 Toric SynergEyes TruEye Other

How long do you wear them?:

N/A None 8 - 10 Hours All day Occ. Overnight Extended Other

What contact solution do you use?:

N/A None Unknown Optifree Clear Care Boston Renu Other

How often do you replace them?:

Daily Weekly 2 weeks Monthly Yearly When uncomfortable Other

Family Eye History

Macular Degen:	None B D F M MA MGF MGM MGPs MU PA PGF PGM PGPs PU S Son Other	Cataracts:	None B D F M MA MGF MGM MGPs MU PA PGF PGM PGPs PU S Son Other
Retinal Detach:	None B D F M MA MGF MGM MGPs MU PA PGF PGM PGPs PU S Son Other	Glaucoma:	None B D F M MA MGF MGM MGPs MU PA PGF PGM PGPs PU S Son Other
Crossed/Lazy Eye:	None B D F M MA MGF MGM MGPs MU PA PGF PGM PGPs PU S Son 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

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

Ethnicity:

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

Medical History

Patient Medical History
Please select from the dropdown menu options:

None Arthritis Diabetes HBP Heart Disease Cancer Lupus Kidney Disease Thyroid Back Problems None Arthritis Diabetes HBP Heart Disease Cancer Lupus Kidney Thyroid Disease Back Problems None Arthritis Diabetes HBP Heart Disease Cancer Lupus Kidney Disease Thyroid Disease Back Problems None Arthritis Diabetes HBP Heart Disease Cancer Lupus Kidney Thyroid Back Problems None Arthritis Diabetes HBP Heart Disease Cancer Lupus Kidney Disease Thyroid Disease Back Problems

Injuries, Surgeries, Hospitalization None Blepharoplasty Blow Out Fx Repair Cataract Sx Corneal Foreign Body Removal Corneal Transplant Enucleation Glaucoma Intravitreal Injections Laser Retinoplexy Punctal Plugs Lower Punctal Plugs Upper Retinal Detachment Sx Strabismus Sx Yag Capsulotomy

Pregnant Or Nursing: No Yes Unsure      Recent Tetanus Shot: No Yes Unsure

Notes:

Primary Care Physician:      Last Visit: Never 1 week 1 month 3 months 6 months 1 year 2 years      Reason For Visit: Check up Annual CL Check Emergency Follow-up Referral

OTC Meds and Vitamins and Drug Allergies

No current meds No Known Drug Allergies

OTC: None Asprin Acetomenophin Ibuprofen Artificial Tears Topical Gels Topical Ointments      Vitamins: None A C Centrum E Lutein Ocuvite Prenatal Preservision Xanten Zinc

Current Medications:


Family Medical History

None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid

Please enter any known family conditions:



Social History

Occupation: Unknown Doctor Domestic Engineer Engineer Firefighter Government worker LNP MEA MTA None Nurse PA Police officer Sales Salesman Slope worker Student Teacher Truck Driver      Hobbies: None Astronomy Art Baseball Boating Basketball Computers (Gaming) Cooking Crafts Dancing Diving Football Fishing Golf Gardening Horseback Riding Hunting Models Needlepoint Painting Photography Piano Racquetball Reading Running Roller Blading Softball Sewing Skiing Soccer Swimming Tennis Video Games Woodworking      STD: None Gonorrhea Syphilis Hepatitis HIV TB

Smoking Status:	Never smoked Current every day smoker Current some day smoker Former smoker Smoker, current status unknown Unknown if ever smoked	Type:	None Cigaretts Chewing Tobacco	How Long:	N/A One year or less One to five years Five to ten years Over ten years
Alcohol:	No Yes Occasionally Socially Heavy	Type:	None Beer Wine Hard Liquor	How Long:	Never Years
Illegal Drugs:	No Yes	Type:		How Long:	Never Weeks Months Years

OSDI

Have you experienced the following?

Sensitivity to light?	Contact lens discomfort?	Watering?	Blurry or fluctuating vision?
Gritty feeling?	Foreign body sensation?	Burning or stinging?	Discharge or crusting?
Dryness?	Redness?	Itching?	Other:

Do you have any history of these conditions?

None Thyroid Arthritis Diabetes Lupus Rosacea Sleep disorder Sarcoid Shingles MS Sjogren's Psorasis Acne HBP Other

Do you take any medications?

None Anti-depressants Antihistamines BCP Beta blockers Diuretics Fosamax Hormone Replacement Therapy Medications for Diabetes Medications for HBP Nasal Coritcosteroids Other

Do any of these factors affect your vision?

None Pregnant/Nursing Tobacco user Frequent air travel Ceiling fan use Prior eye surgery Extended computer use Allergies Cold and/or Dry weather Other

Do you take any eye medications? (topical meds/rewetting drops included):

If you wear contacts, what kind?:

None Acuvue 1-Day Define Acuvue 1 Day Moist Acuvue 2 Acuvue 2 Colors Acuvue Advance Acuvue Advance Plus Acuvue Bifocal Acuvue Oasys Advance Toric Air Optix Air Optix Aqua N&D Air Optix Multifocal Air Optix Toric Aqua Clear Aqua Clear 100 Aqua Clear 100 Toric Aqua Clear Toric Avaira Avaira Toric B&L ULTRA Biofinity Biofinity Multifocal Biofinity Toric Biomedics 55 Biomedics 55 Premium Biomedics Toric Biomedics XC BioTrue ONEday BioTrue ONEday Multifocal Boston ES Boston II Boston IV Boston XO Clariti 1-Day Daily Totals 1 DT 1 F 55 Toric Focus Dailies Focus Dailies Toric Freq 55 Freq 55 Aspheric Freshlook Colors Freshlook VT Oasys Multifocal Oasys Toric Paragon HDS Paragon Thin Polycon II Proclear ProClear Multifocal ProClear Multifocal Toric ProClear toric ProClear Toric XR PureVision PureVision Toric PureVision Toric PureVsion 2 HD Rose K Sauflon Soflens 38 Soflens 66 Toric SynergEyes TruEye Other

How do they feel?:

None No Issues Burns Comfortable Dry Feels CL on eye Irritated Itchy Red Uses rewetting gtts a lot Other

Review of Systems

General:	none fatigue fever loss of appetite weight gain weight loss Other	Ear/Nose/Throat:	none chronic cough congestion daytime drowsiness dry throat / mouth gasp while sleeping headache hearing problems heavy snoring morning headaches runny nose sinus problems sleep apnea tinnitus toothache Other
Respiratory:	none asthma cronchitis cyanosis emphysema productive cough shortness of breath wheezing Other	Cardiovascular:	none chest pain heart disease high cholesterol hypertension racing heartbeat shortness of breath swollen feet/ankles vascular disease Other
Skin:	none acne eczema itching psoriasis rosacea keloids Other	Genital/Kidney/Bladder:	none impotence jaundice overactive bladder painful urination painful urination underactive bladder urgency in urination urinary incontinence Other
Neurological:	none balance problems changes in senses dementia memory problems muscle weakness numbness, paralysis personality changes speech problems tremors vertigo Other	Muscles/Bones/Joints:	none arthritis decreased range of motion muscle cramps pain/tenderness stiffness swelling weakness Other
Psychiatric:	none anxiety depression insomnia obsessive/compulsive paranoia suicidal violence Other	Gastrointestinal:	none abdominal pain acid reflux bloody stools constipation Crohn's disease dark urine diarrhea gastric reflux (GERD) IBS jaundice nausea ulcer vomiting Other
Endocrine:	none diabetes hypothyroid hyperthoyroid Other	Allergic/Immunologic:	none asthma hives itching mild allergy symptoms redness severe allergy symptoms sneezing swelling Other
Blood/Lymph:	none anemia bleeding gums cuts slow to clot easy bruising hx of significant blood loss nosebleeds pale skin pounding in ears rapid heartbeat shortness of breath Other

Signature/Submit

Notice of Health Information Practices (HIPAA)

By signing below:

- I give Valley Eye Associates/Dr.Coon permission to leave messages regarding appointments on an answering machine or service if I am unavailable.

-I give Valley Eye Associates/Dr.Coon permission to fax medical and ocular prescriptions to pharmacies or offices of my choice.

- I give Valley Eye Associates/Dr.Coon permission to discuss medical or billing information to the people listed below in the event of an emergency or otherwise.

Name: Phone Number: Relation:

Name: Phone Number: Relation:

Name: Phone Number: Relation:

I acknowledge and agree that I have received a copy of Valley Eye Associate’s notice of privacy practices. The copy of our full privacy policy is available at reception, at any time, please take one for your records if you desire.

Patient Signature: Date:

Patient Printed Name: