Online Patient Form

Patient Info

Patient Information

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	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. Fr. 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:

Primary Insurance

Insurance Information

Insurance Name:	None New Insurance AARP Advantica Aetna Aggieland Lions Club All Savers Allied Always Care Ameritas Ancillary Care Services (ACS) Assurance Health Avesis Best Life Health Insurance Block Vision Blue Cross Blue Shield Care Improvement Plus Cigna HealthCare Davis Discount Davis Vision Discount Plan Only Entrust Eye Med Eyemed Discount Eyetopia Freedom Life GEHA GPA Health First Health for all Humana Humana Vision Intergovernmental Employee Benefits Pool Lions Club Lions Club Caldwell Medicaid Standard TMHP Medicare Part B Medicare Supplement MES Vision Metlife-VSP discount National Guardian Life Insurance Company National Vision Admin National Vision Administrator NCERA Principal Financial Group Safe Guard Vision Network Scott & White Health Plan Security Life Ins Company Spectera Superior Discount Superior Vision Supplemental Insurance TEEX Texas Regional TriCare TriWest UMR United Healthcare VA Vision Benefits of America Vision Care Direct Vision Service Plan VSP Discount Plan VSP Gift Certificate
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

Insurance Information

Insurance Name:	None New Insurance AARP Advantica Aetna Aggieland Lions Club All Savers Allied Always Care Ameritas Ancillary Care Services (ACS) Assurance Health Avesis Best Life Health Insurance Block Vision Blue Cross Blue Shield Care Improvement Plus Cigna HealthCare Davis Discount Davis Vision Discount Plan Only Entrust Eye Med Eyemed Discount Eyetopia Freedom Life GEHA GPA Health First Health for all Humana Humana Vision Intergovernmental Employee Benefits Pool Lions Club Lions Club Caldwell Medicaid Standard TMHP Medicare Part B Medicare Supplement MES Vision Metlife-VSP discount National Guardian Life Insurance Company National Vision Admin National Vision Administrator NCERA Principal Financial Group Safe Guard Vision Network Scott & White Health Plan Security Life Ins Company Spectera Superior Discount Superior Vision Supplemental Insurance TEEX Texas Regional TriCare TriWest UMR United Healthcare VA Vision Benefits of America Vision Care Direct Vision Service Plan VSP Discount Plan VSP Gift Certificate
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:

New Pt. History

Chief Complaint
Select the option that best fits the main reason for your visit today: Comprehensive Eye Exam Medical Eye Problem (Red Eye) Diabetic eye exam Glaucoma Check Failed screening at pediatrician's office Failed screening at school Broken glasses Need more contacts Need new glasses Want to be fitted for contacts
Please describe any symptoms you may be experiencing: (Ex: blurred vision, eye pain, etc.)

Select the following options that fit the symptoms mentioned above.
Duration ongoing 1 day 2 days 3 days 4 days 5 days 6 days 1 week 1 month 3 months 6 months 1 year >1 year Quality no change worse better throbbing slightly worse a little better much better Vision is good Secerity Mild Moderate Severe Location Both eyes Right eye Left eye


Personal Eye History
*If you answer yes to any of the 3 following questions, please fill out the Dry Eye Questionnaire as well.*
1. Are you ever aware of your eyes? (Grittiness, sandiness, watery, itchy)
2. Do you use any artificial tears?
3. Are your eyes sometimes red?
Enter any previous eye conditions:
Have you had any eye surgeries? None Cataract Surgery LASIK Glaucoma Surgery What kind of eye drops do you use? None Alphagan Alrex Blink Cromolyn NA 4% Elestat Genteal Lotemax Optive Patanol Pred Forte Refresh Restasis Rewetting drops Systane Systane Balance Theratears Travatan Vigamox Visine Xalatan
When was your last eye examination?
Last Exam Date Never 1 year 2 years 3 years Doctor's Name
Primary Vision Correction None Glasses-Full Time Glasses-Readers Only Contacts - Soft Contacts - Hard OTC readers
Are you looking for new glasses? No Yes Do you have backup sunglasses? No Yes Do you have backup specs? No Yes
If you wear contacts, please fill out the following options:
Name/Brand of Contacts: How often do you dispose of your contacts? daily monthly weekly yearly Quarterly bimonthly Wear Time Less than 6hrs 8 - 10 Hours All day 1 wk Multiple weeks 1 Month Longer than 1 month

Family Eye History
Please select which family members (if any) have been diagnosed with the following conditions:
Crossed / Lazy Eye None Mother Father Sibling Grandmother Grandfather Unknown Retinal Detachment Mother Father Sibling Grandmother Grandfather Unknown Macular Degeneration Mother Father Sibling Grandmother Grandfather Unknown Cataracts Mother Father Sibling Grandmother Grandfather Unknown Glaucoma Mother Father Sibling Grandmother Grandfather Unknown

Personal Medical History
No known medical conditions (check this box)
Have you been diagnosed with any medical conditions? Please check all that apply:

Diabetes	No Yes - T1 diabetes Yes - T2 diabetes	When were you diagnosed?	1 yr 2 yrs 3-5 yrs 5-10 yrs 10+ yrs	Latest HBA1C Percentage

Hypertension

High Cholesterol

Thyroid Condition

Cancer

Any other conditions not listed above:

Medications	Vitamins
Allergies

Primary Care Physician

Family Medical History

Please use the following boxes to select all conditions that apply.

1.

None Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid

2.

3.

4.

5.

Personal Information:
Occupation:		Hobbies:	Astronomy Art Baseball Boating Basketball Cooking Crafts Dancing Diving Football Fishing Golf Gardening Horseback Riding Hunting Models Needlepoint None Painting Photography Piano Reading Running Roller Blading Softball Sewing Skiing Soccer Swimming Tennis Video Games Woodworking
Smoking Status:	Never Smoker Current every day smoker Current some day smoker Former smoker	Type:	None Cigaretts Cigars Chewing Tobacco	How Long:

Alcohol:

No Yes Occasionally Socially

Type:

None Beer Wine Hard Liquor No Preference

How Long:

Do you currently use any illegal drugs?

No Yes No Response

Type: How Long:

Do you have any Sexually Transmitted Diseases?

None Gonorrhea Syphilis Hepatitis HIV AIDS TB

Est. Pt. History

Chief Complaint
Select the option that best fits the main reason for your visit today: Comprehensive Eye Exam Medical Eye Problem (Red Eye) Diabetic eye exam Glaucoma Check Failed screening at pediatrician's office Failed screening at school Broken glasses Need more contacts Need new glasses Want to be fitted for contacts
Please describe any symptoms you may be experiencing: (Ex: blurred vision, eye pain, etc.)

Select the following options that fit the symptoms mentioned above.
Duration ongoing 1 day 2 days 3 days 4 days 5 days 6 days 1 week 1 month 3 months 6 months 1 year >1 year Quality no change worse better throbbing slightly worse a little better much better Vision is good Secerity Mild Moderate Severe Location Both eyes Right eye Left eye


Personal Eye History
*If you answer yes to any of the 3 following questions, please fill out the Dry Eye Questionnaire as well.*
1. Are you ever aware of your eyes? (Grittiness, sandiness, watery, itchy)
2. Do you use any artificial tears?
3. Are your eyes sometimes red?
Are you looking for new glasses? No Yes Do you have backup sunglasses? No Yes Do you have backup specs? No Yes
If you wear contacts, please fill out the following options:
How often do you dispose of your contacts? daily monthly weekly yearly Quarterly bimonthly Wear Time Less than 6hrs 8 - 10 Hours All day 1 wk Multiple weeks 1 Month Longer than 1 month

Dry Eye Questionnaire

Symptoms	Frequency of Symptoms	Severity of Symptoms
	Rate 0 to 3	Rate 0 to 4
Dryness, grittiness, or scratchiness	0 1 2 3	0 1 2 3 4
Soreness or irritation	0 1 2 3	0 1 2 3 4
Burning or watering	0 1 2 3	0 1 2 3 4
Eye fatigue	0 1 2 3	0 1 2 3 4
Fluctuating Vision	0 1 2 3	0 1 2 3 4

Frequency Legend:	Severity Legend:
0=Never	0=No Problems
1=Sometimes	1=Tolerable, not perfect but not uncomfortable
2=Often	2=Uncomfortable, irritating but does not interfere with my day
3=Constant	3=Bothersome, irritating and interferes with my day
	4=Intolerable, unable to perform my daily tasks

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