Online Patient Form

Demographics

Patient Information

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:
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 #

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Billing Information

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

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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 New Insurance New Insurance AARP UHC ADMINISTAR FEDERAL Aetna Aetna Better Health of Virginia Anthem BMW Lions Club CareFirst Blue Cross Blue Shield Cigna Allegiance Cigna Health Care Cigna Payer Solutions Cigna Vision Commonwealth Eye Care Associates Coventry EyeMed Eyemed Discount Humana Humana Vision M.D.I.P.A (UNHC) March Vision Care Medicaid Medicare Railroad Mid-Atlantic Carpenters Fund New Insurance OneNet Optima Health OTHER Palmetto GBA Self Pay Superior Vision TLC Laser Eye Center Today's Options PPO Tricare UHC Medica UHC Medicare Solutions United Health Care-GEHA United Health Care Community Plan United Health Care GA United Healthcare Medicare Solutions United Healthcare Vision Virginia Premier Claims Vision Care plan VSP WHITTEN LASER PLUS
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 Information

Insurance Name:	None New Insurance New Insurance AARP UHC ADMINISTAR FEDERAL Aetna Aetna Better Health of Virginia Anthem BMW Lions Club CareFirst Blue Cross Blue Shield Cigna Allegiance Cigna Health Care Cigna Payer Solutions Cigna Vision Commonwealth Eye Care Associates Coventry EyeMed Eyemed Discount Humana Humana Vision M.D.I.P.A (UNHC) March Vision Care Medicaid Medicare Railroad Mid-Atlantic Carpenters Fund New Insurance OneNet Optima Health OTHER Palmetto GBA Self Pay Superior Vision TLC Laser Eye Center Today's Options PPO Tricare UHC Medica UHC Medicare Solutions United Health Care-GEHA United Health Care Community Plan United Health Care GA United Healthcare Medicare Solutions United Healthcare Vision Virginia Premier Claims Vision Care plan VSP WHITTEN LASER PLUS
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:

Tertiary

Insurance Information

Insurance Name:	None New Insurance New Insurance AARP UHC ADMINISTAR FEDERAL Aetna Aetna Better Health of Virginia Anthem BMW Lions Club CareFirst Blue Cross Blue Shield Cigna Allegiance Cigna Health Care Cigna Payer Solutions Cigna Vision Commonwealth Eye Care Associates Coventry EyeMed Eyemed Discount Humana Humana Vision M.D.I.P.A (UNHC) March Vision Care Medicaid Medicare Railroad Mid-Atlantic Carpenters Fund New Insurance OneNet Optima Health OTHER Palmetto GBA Self Pay Superior Vision TLC Laser Eye Center Today's Options PPO Tricare UHC Medica UHC Medicare Solutions United Health Care-GEHA United Health Care Community Plan United Health Care GA United Healthcare Medicare Solutions United Healthcare Vision Virginia Premier Claims Vision Care plan VSP WHITTEN LASER PLUS
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:

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History

Referred By:

None Google Insurance LensCrafters Other

Accompanied by (enter name):

n/a unknown Other

Relationship

n/a fiancee friend guardian parent sibling husband wife family daughter son mother father Other

Marital status

Unknown Married Single Divorced Separated Engaged Other Other

Ethnicity

Unknown White African American Asian Hispanic Indian Other

Employer / School

Unknown Other

Occupation / Grade in school

None reported Other

Hobbies:

None Listed 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 Other

Medications	None Abilify Accupril ACE Inhibitors Acetominophen Acromycin Adderall Advil Afrin Albuterol Amoxicillin Ampicillin Anafranil Anaprox Antibiotics Antihistamines Aspirin Atropine Augmentin Avelox Azithromycin Bacitracin Bactrim Benadryl Benzoil Peroxide Benzomycin Biaxin Birth control Cardivol Ceclor Cefprozil Ceftin Celebrex Cephalosporin Chloroquine Ciprofloxacin Clarithromycin Claritin Cleocin Clindomycin Cliomycin Codeine Colymycin Compazine Contrast dye Coreg Crestor Cyclines Cymbalta Darvon Darvoset Daypro Demerol Dimetab Diovan Doxycycline Effexor Entex Environmental Ephedrine Erythromycin Flagil Floxin Fluorescein dye Fluoroquinolones Haladol Hormone replacement therapy Humira Hydrochlorothiazide Hydroxazine Ibuprofen Ilisone Imitrex Imuran Insulin Iodine IVP Dye Keflex Lamictal Lamisil Levoquin Lexapro Lipitor Liquid meds Lisinopril Macrobid Macrodantin Maxalon Mercury Metformin Metronidazole Minocin Morphine Motrin Mycins Naproxin Neomycin Neosporin Neurontin Nexium Niacin Nitrous Oxide Nizoral Novocaine NSAID's Oral contraceptives PABA Penicillin Percoset Phenergan Phenobarbital Phenolpropanolamine Phenothiazines Pherenol Prevacid Propecia Provigil Pseudephedrine Pseudofed Quinine Relafen Remicade Rifampin Risperdal Ritalin Seldane Septra Stemetil Steroids Succinylcholine Sulfa Synthroid Tagamet Tetanus Vaccine Tetracycline Thimerasol Thorazine Trimethoprim Tylenol Valium Vancomycin Vantin Versed Vibramycin Vicodin Vioxx Vitamins Voltaren Wellbutrin Xopenex Zestril Zithromax Zoloft Zomig Zyrtec Other	Allergies	NKDA Abilify Accupril ACE Inhibitors Acetominophen Acromycin Adderall Advil Afrin Albuterol Amoxicillin Ampicillin Anafranil Anaprox Antibiotics Antihistamines Aspirin Atropine Augmentin Avelox Azithromycin Bacitracin Bactrim Benadryl Benzoil Peroxide Benzomycin Biaxin Birth control Cardivol Ceclor Cefprozil Ceftin Celebrex Cephalosporin Chloroquine Ciprofloxacin Clarithromycin Claritin Cleocin Clindomycin Cliomycin Codeine Colymycin Compazine Contrast dye Coreg Crestor Cyclines Cymbalta Darvon Darvoset Daypro Demerol Dimetab Diovan Doxycycline Effexor Entex Environmental Ephedrine Erythromycin Flagil Floxin Fluorescein dye Fluoroquinolones Haladol Hormone replacement therapy Humira Hydrochlorothiazide Hydroxazine Ibuprofen Ilisone Imitrex Imuran Insulin Iodine IVP Dye Keflex Lamictal Lamisil Levoquin Lexapro Lipitor Liquid meds Macrobid Macrodantin Maxalon Mercury Metformin Metronidazole Minocin Morphine Motrin Mycins Naproxin Neomycin Neosporin Neurontin Nexium Niacin Nitrous Oxide Nizoral Novocaine NSAID's Oral contraceptives PABA Penicillin Percoset Phenergan Phenobarbital Phenolpropanolamine Phenothiazines Pherenol Prevacid Propecia Provigil Pseudephedrine Pseudofed Quinine Relafen Remicade Rifampin Risperdal Ritalin Seldane Septra Stemetil Steroids Succinylcholine Sulfa Synthroid Tagamet Tetanus Vaccine Tetracycline Thimerasol Thorazine Trimethoprim Tylenol Valium Vancomycin Vantin Versed Vibramycin Vicodin Vioxx Vitamins Voltaren Wellbutrin Xopenex Zestril Zithromax Zoloft Zomig Zyrtec Other
PATIENT MEDICAL HISTORY	No problems reported Acne Acoustic neuroma ADD Addison's Disease Allergies/Hay fever Alopecia Anemia Angina Ankylosing spondylitis Anti-phospholipid Syndrome Anxiety Disorder Aortic aneurysm Arthritis Arythmia Asher's Syndrome (RP) Asthma Atrial fibrillation Bell's Palsy Bipolar Disorder Blood clot BPH Bradycardia Breast Cancer Bronchitis C.V Neuralagia Cancer Cardio Myopathy Cerebellar inbalance Cerebral Palsy Chronic Glomeronephritis Colitis COPD Coronary Artery Disease Crohn's Disease Depression Dermatitis Diabetes Diverticulitis Dry Eyes Eating disorder Eczema Encephalitis Epilepsy Esophageal ulcer Fibromyalgia Gastrointestinal Disorder GERD Gestational diabetes Glaucoma Gout Grave's Disease Hashimoto's Thyroiditis HAV HBV HCV Headaches Heart Disease Heart Murmur Hemochromatosis High blood pressure HIV HRT HSV HTN Hypercholesterolemia Hyperglycemia Hyperhydrosis Hyperthyroid Hypoglycemia Hypothyroid IDDM Insomnia Irritable Bowel Syndrome Ischemic Heart Disease Kidney stones Lactose Intolerant Leukemia Low Blood Pressure Lower Back Injury Lumbar stenosis Lupus Lymphoma Malaria Malignant Melanoma Meniere's Disease Migraine Headaches Mitral valve prolapse Mood Disorder MS Myasthenia gravis Myotonic Muscular Dystrophy Narcolepsy Neuralgia Neuro-cardiogenic Syncope Neuropathy NIDDM Non-Hodgkins Lymphoma Nursing OCD Optic neuritis Osteopenia Osteoporosis Parkinson's Disease Peptic Ulcer Perforated ulcer Phlebitis Pituitary tumor PMS Polycystic Ovarian Syndrome Polycythemia rubravara Polymyositis Pregnant Prolactinoma Prostate cancer Prosthetic Heart Valve Pseodotumor cerebri Psoriasis Psychotic episodes Recovering Alcoholic Reiter Syndrome Respiratory problems Rheumatoid Arthritis Rhinitis Rosacea RP Sarcoidosis Schizophrenia Sciatica Seizures Sinus problems Sjogrens Syndrome Skin cancer Sleep apnea Spinal cord injury Stenosis Stomach Ulcer Stroke Tachycardia Thalassemia Tinnitus Toe fungus Ulcerative colitis Urinary Incontinence Vascular Disease Vertigo Vitiligo Von Willebrand Disorder Water Retention Wegener's Syndrome Weight control No problems reported Other

Diabetic

Yr dx:

n/a unknown Other

Diabetic Prescription:

None Abilify Accupril ACE Inhibitors Acetominophen Acromycin Adderall Advil Afrin Albuterol Amoxicillin Ampicillin Anafranil Anaprox Antibiotics Antihistamines Aspirin Atropine Augmentin Avelox Azithromycin Bacitracin Bactrim Benadryl Benzoil Peroxide Benzomycin Biaxin Birth control Cardivol Ceclor Cefprozil Ceftin Celebrex Cephalosporin Chloroquine Ciprofloxacin Clarithromycin Claritin Cleocin Clindomycin Cliomycin Codeine Colymycin Compazine Contrast dye Coreg Crestor Cyclines Cymbalta Darvon Darvoset Daypro Demerol Dimetab Diovan Doxycycline Effexor Entex Environmental Ephedrine Erythromycin Flagil Floxin Fluorescein dye Fluoroquinolones Haladol Hormone replacement therapy Humira Hydrochlorothiazide Hydroxazine Ibuprofen Ilisone Imitrex Imuran Insulin Iodine IVP Dye Keflex Lamictal Lamisil Levoquin Lexapro Lipitor Liquid meds Lisinopril Macrobid Macrodantin Maxalon Mercury Metformin Metronidazole Minocin Morphine Motrin Mycins Naproxin Neomycin Neosporin Neurontin Nexium Niacin Nitrous Oxide Nizoral Novocaine NSAID's Oral contraceptives PABA Penicillin Percoset Phenergan Phenobarbital Phenolpropanolamine Phenothiazines Pherenol Prevacid Propecia Provigil Pseudephedrine Pseudofed Quinine Relafen Remicade Rifampin Risperdal Ritalin Seldane Septra Stemetil Steroids Succinylcholine Sulfa Synthroid Tagamet Tetanus Vaccine Tetracycline Thimerasol Thorazine Trimethoprim Tylenol Valium Vancomycin Vantin Versed Vibramycin Vicodin Vioxx Vitamins Voltaren Wellbutrin Xopenex Zestril Zithromax Zoloft Zomig Zyrtec Other

Last BS

n/a unknown Other

Date

n/a unknown Other

Last A1C

n/a unknown Other

Date

n/a unknown Other

OTC supplements

None Advil Asprin Ibuprofen Multivitamin Ocular vitamin Omega-3 Vitamin A Vitamin B Vitamin C Vitamin D Other

Tobacco use

none 1/2 ppd 1 ppd 1.5 ppd social smoker chewing Other

Year started

n/a Other

Alcohol use

None Rare Light Moderate Heavy Other

Illegal Drugs

none marijuana Other

Pregnant Or Nursing

No Yes Unsure Other

Due date / DOB

n/a Other

Blood-related family member medical problems:

none Diabetes High cholesterol High Blood Pressure Rheumatoid Arthritis Other

Relationship

Unknown n/a grandparent parent sibling Other

Other:

n/a dementia mental retardation Other

Primary Language

English Other

Review Of Systems

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

GENERAL: Fever, Weight loss, Weight gain, Fatigue

None Fever Weight gain Weight Loss Other

INTEGUMENTARY: Growths, Rashes, Acne

None Growths Rash Acne Warts Other

NEUROLOGICAL: Headaches, Migraines, Seizures

None Numbness, paralysis Headache Seizures Migraines Multiple sclerosis Other

ENDOCRINE: Thyroid, Diabetes

None Hypothyroid Hyperthyroid Diabetes Other

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 Other

RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD

None Asthma Bronchitis Emphysema COPD Other

CARDIOVASCULAR: Hypertension, Heart Surgery, Vascular Disease

None Surgery Vascular Disease Hypertension Heart Disease Diabetes High Cholesterol Other

GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

None Diarrhea Constipation Ulcer Acid Reflux Irritable bowel syndrome Other

GENITOURINARY: Kidney Stones, Frequent Urination, Impotence, BPH

None Painful urination Frequent urination Impotence BPH Kidney stones Other

MUSCULOSKELETAL: Athritis, Joint Pain, Head or Neck Injury

None Arthritis Joint pain Muscle pain Stiffness Swelling Cramps Osteoporosis Osteopenia Other

HEMATOLOGIC/LYMPHATIC: Anemia, Bleeding problems

None Bleeding Anemia Other

ALLERGIC/IMMUNOLOGIC: Seasonal Allergies, Allergy Shots

None Sneezing Swelling Redness Itching HIV Hives Lupus Lyme Disease Sarcoidosis Other

PSYCHIATRIC: Depression, Anxiety, Insomnia

None Anxiety Depression Insomnia ADD ADHD Bi-polar disorder Other

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

Ocular

Last full exam
Unknown Never 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Other	Location	unknown Stony Point Regency LensCrafters - CTC LensCrafters - Willow Lawn LensCrafters - Short Pump Village Marketplace Village Marketplace - Peery Other	Age of glasses	Unknown n/a 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Other	Wear type	n/a all the time distance only near only as needed, d and n backup for CLs Other

Eyedrops or ocular vitamins

None Alaway AlphaganP Alrex brimonidine Generic art tear Generic vitamin Icaps Lotemax Lumigan Ocuvite Optive Pataday Patanol Preservision Soothe Systane Timolol 0.25% Timolol 0.5% Timoptic Timoptic XE Travatan Trusopt Visine Visine GTRO Xalatan Zaditor Other

Eye surgeries or injuries

None Cataract sx Glaucoma sx LASIK Retinal Sx Other

Which Eye(s)

n/a OD OS OU Other

Date

n/a < 2010 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Other

Patient history of eye problems

None Age-related macular degeneration Cataract Dry eye Glaucoma Lazy eye / Strabismus Other

Date of onset

n/a Unknown Other

Family history of eye disease

None Blindness Glaucoma Lazy eye / strabismus Macular Degeneration Other

Relationship

n/a Grandparent Mother Father Sibling Other

MEDICAL CHIEF COMPLAINT

Blurry vision Blurred Distance Vision Blurred Near Vision Blurry with glasses Burning CL stuck in eye Corneal ulcer Diabetes Discharge Discomfort Dizziness Dry eyes Eye fatigue Flashing light Floaters Foreign body sensation Glaucoma suspect Halo around lights Headaches Ingrown lash Irritation Itchy eyes Lid twitch Light sensitive Photophobia Prior cataract surgery Recurrent erosion Red eye Retinal image Scratched cornea Stye Swollen lid Vertigo Vision loss Watery eyes Annual Exam, No Visual complaints with current SRx Decreased Distance and Near Vision Decreased Distance Vision Other

Eye(s)

n/a OD OS OU Other

Frequency

n/a constant daily intermittent 1x/week 2-4x/week 2-4x/month Other

Date of onset

n/a Unknown < 2010 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Other

Relief

None n/a SRx SRx or CLs Other

Duration

n/a Minutes Hours Days Other

Severity

n/a mild moderate severe Other

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