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. Poppenhussen Dr. Saavedra Dr. Murray Dr. Tran 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 Medications:

Ocular Medications:

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

Family Med History:

Family Eye History (Glaucoma, RD, blindness):

Allergies:

Smoke?

No Yes Occasional

Alcohol?

No Yes Social

Major Surgery or Illness

Hx of Eye Injury

No Yes

Hx of Eye Disease: (ex: 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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