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

Race:

Caucasian Asian Hispanic or Latino Black or African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Other

Preferred Language:

English Spanish Vietnamese French German Other

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 New Insurance New Insurance No Name No Name Aetna Always Care Benefits, Inc American Administrative Group American PPO Ancillary Care Services Avesis Vision BCBS Blue Bell Creameries BMA Bravo Health Medicare HMO Care Improvement Plus/XL Health Cigna Coast to Coast Vision Discount Plan Coastal Comp Health Network PPO/WC Community Health Choice Davis Vision Emerald Health Network Empire Blue Cross and Blue Shield Employee Benefits Management Corp Employers Health Network Entrust Epsi Evercare Medicare Evolution Healthcare Systems Eye Care For Kids Eyeconic Eyemed Eyetopia Vision First Health First Look Vision-Always Care Focus HealthCare Fortified Provider Network Galaxy Health Network Great-West Healthcare Guardian Health Management Network Health Smart PPO HealthMarkets Humana Humana Military Tricare IHG IMS Insurance Design Administrators Insurers Administrative Corporation InterGroup Services Corporation Iron Workers Local Trust Fund Kelsey Care Advantage Key Healthy Liberty Health Share Marsh Medicare Advantra Medicare of Texas Memorial Herman MES Vision Molina Medicare Multiplan PPO National Choice Care National Healthcare Alliance National Preffered Provider Network National Provider Network PPO National Vision Administrator New Insurance Opticare Eye Health Network Optum Health Vision - Spectera Plan Care America Plan Vista Solutions (NPPN) Plasterers Local PPONext (HHPO/Medical Contraol, Inc.) Premera Blue Cross Prime Health Services Inc. Principal Financial Group Private Healthcare System PPO Professional Claims Management SafeGuard Vision Southwest Medical PPO Spectera Superior Vision Texas Athletic Network Texas Municipal League PPO Three Rivers Provider Network Traditional Medicaid Tricare Prime Tricare Standard Twelve Oaks IPA UHC UMR United Health Care Vision United Healthcare Medicare Supplement Plans United Payors & United Provider PPO USA Managed Care Organization PPO VCP Vision Benefits of America VSP Choice VSP Signature Wellcare HMO Medicare XL Health Medicare HMO
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 No Name No Name Aetna Always Care Benefits, Inc American Administrative Group American PPO Ancillary Care Services Avesis Vision BCBS Blue Bell Creameries BMA Bravo Health Medicare HMO Care Improvement Plus/XL Health Cigna Coast to Coast Vision Discount Plan Coastal Comp Health Network PPO/WC Community Health Choice Davis Vision Emerald Health Network Empire Blue Cross and Blue Shield Employee Benefits Management Corp Employers Health Network Entrust Epsi Evercare Medicare Evolution Healthcare Systems Eye Care For Kids Eyeconic Eyemed Eyetopia Vision First Health First Look Vision-Always Care Focus HealthCare Fortified Provider Network Galaxy Health Network Great-West Healthcare Guardian Health Management Network Health Smart PPO HealthMarkets Humana Humana Military Tricare IHG IMS Insurance Design Administrators Insurers Administrative Corporation InterGroup Services Corporation Iron Workers Local Trust Fund Kelsey Care Advantage Key Healthy Liberty Health Share Marsh Medicare Advantra Medicare of Texas Memorial Herman MES Vision Molina Medicare Multiplan PPO National Choice Care National Healthcare Alliance National Preffered Provider Network National Provider Network PPO National Vision Administrator New Insurance Opticare Eye Health Network Optum Health Vision - Spectera Plan Care America Plan Vista Solutions (NPPN) Plasterers Local PPONext (HHPO/Medical Contraol, Inc.) Premera Blue Cross Prime Health Services Inc. Principal Financial Group Private Healthcare System PPO Professional Claims Management SafeGuard Vision Southwest Medical PPO Spectera Superior Vision Texas Athletic Network Texas Municipal League PPO Three Rivers Provider Network Traditional Medicaid Tricare Prime Tricare Standard Twelve Oaks IPA UHC UMR United Health Care Vision United Healthcare Medicare Supplement Plans United Payors & United Provider PPO USA Managed Care Organization PPO VCP Vision Benefits of America VSP Choice VSP Signature Wellcare HMO Medicare XL Health Medicare HMO
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 No Name No Name Aetna Always Care Benefits, Inc American Administrative Group American PPO Ancillary Care Services Avesis Vision BCBS Blue Bell Creameries BMA Bravo Health Medicare HMO Care Improvement Plus/XL Health Cigna Coast to Coast Vision Discount Plan Coastal Comp Health Network PPO/WC Community Health Choice Davis Vision Emerald Health Network Empire Blue Cross and Blue Shield Employee Benefits Management Corp Employers Health Network Entrust Epsi Evercare Medicare Evolution Healthcare Systems Eye Care For Kids Eyeconic Eyemed Eyetopia Vision First Health First Look Vision-Always Care Focus HealthCare Fortified Provider Network Galaxy Health Network Great-West Healthcare Guardian Health Management Network Health Smart PPO HealthMarkets Humana Humana Military Tricare IHG IMS Insurance Design Administrators Insurers Administrative Corporation InterGroup Services Corporation Iron Workers Local Trust Fund Kelsey Care Advantage Key Healthy Liberty Health Share Marsh Medicare Advantra Medicare of Texas Memorial Herman MES Vision Molina Medicare Multiplan PPO National Choice Care National Healthcare Alliance National Preffered Provider Network National Provider Network PPO National Vision Administrator New Insurance Opticare Eye Health Network Optum Health Vision - Spectera Plan Care America Plan Vista Solutions (NPPN) Plasterers Local PPONext (HHPO/Medical Contraol, Inc.) Premera Blue Cross Prime Health Services Inc. Principal Financial Group Private Healthcare System PPO Professional Claims Management SafeGuard Vision Southwest Medical PPO Spectera Superior Vision Texas Athletic Network Texas Municipal League PPO Three Rivers Provider Network Traditional Medicaid Tricare Prime Tricare Standard Twelve Oaks IPA UHC UMR United Health Care Vision United Healthcare Medicare Supplement Plans United Payors & United Provider PPO USA Managed Care Organization PPO VCP Vision Benefits of America VSP Choice VSP Signature Wellcare HMO Medicare XL Health Medicare HMO
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

Reason for Visit:	distance vision blurry near vision blurry vision blurry distance and near red eye pain in eye loss of vision injury to eye needs new glasses wants to be fitted for contacts itching burning stinging dry eyes Diabetic eye exam Other
Secondary Reasons:

Whom may we thank for referring you	Self referral Family friend Coworker Doctor Walk-in Insurance Company Internet search Facebook Twitter YELP Email ad Postcard ad Newspaper ad Radio ad TV ad Other
Address or Phone Number

If you are a returning patient: Which reminder did you receive?

Email Text Phone None Other

Today's Visit

Chief Visual Complaint:

Poor Distance Vision Poor near vision Fluctuating vision Double vision Night blindness Loss of side vision Loss of central vision Loss of or very limited Red eye Eye pain Dry eyes Other

Which Eye?:

Right Left Both Other

Symptoms

None Headaches Yellow Discharge White ropey discharge Watery discharge Itching Red eyes Eye pain/soreness Dry eyes Sandy gritty feeling Flashes of light Floaters Glare/Light sensitivity curtain over eye Other

Onset

Meds Used

CL Wearer

NO YES Other

Secondary Complaint

BLURRY VISION (FAR) BLURRY VISION (NEAR) Wanted to evaluate the visual and health status of the eyes - OU LOST GLASSES BROKEN GLASSES HEADACHES DRY SCHOOL NURSE REFERRAL DPS REFERRAL DIABETIC EYE EXAM FLASHES FLOATERS EXCESSIVE CLOSE WORK BURNING ITCHY OTHER Other

Eye History

Last Eye Exam:

cannot remember 1 year 2 years 3 years never years ago Other

Diagnosis:

No Visual problems don't remember Myopia Hyperopia Astigmatism Presbyopia Amblyopia Other

Doctor Prescribed:

Nothing Eyeglasses Contact lenses Prescription sunglasses Computer glasses Safety glasses Sports Glasses Other

Last eye doctors name

Don't remember Other

Doctor's Address

Don't remember Other

Doctor's Telephone:

Don't remember Other

Please check all eye conditions that apply to you

Good Ocular Health None Itching Burning, Stinging Eye Surgery Flashes Of Light Floaters was told "might have glaucoma" Glaucoma Cataracts Cataract surgery Strabismus/no surgery Strabismus surgery "Lazy eye" (Amblyopia) Corneal ulcer Recurrent infections Lasix RK PRK Macula degeneration Diabetic retinopathy/laser trmt Diabetic retinopathy/monitering Recurrent hordeolum foreign body history Eye injury w/ vision loss Eye injury w/o vision loss Retinal problem/unknown dx keratoconus Corneal dystrophy Other

Have you ever had any Eye surgeries?

None Lasik OU Blepharoplasty OU Cataract OU Cataract OD Cataract OS Lasik enhance Strabismus Laser Retinal Repair Cryo Retinal Repair Scleral Buckle Lasik PRK PRK enhance YAG Cap OD OS OU Other

Procedure Date:

Family Members With Eye Conditions (Blood Relatives Only):

My	Mother Father Grandmother Grandfather Brother Sister Other	Has	Myopia Hyperopia Astigmatism Presbyopia Ambloyopia Corneal dystrophy Dry eyes Cataracts Glaucoma Diabetic Retinopathy Hypertensive Retinopathy Crossed/Lazy eye Macular degeneration Eye trauma Other
My	Mother Father Grandmother Grandfather Brother Sister Other	Has	Myopia Hyperopia Astigmatism Presbyopia Ambloyopia Corneal dystrophy Dry eyes Cataracts Glaucoma Diabetic Retinopathy Hypertensive Retinopathy Crossed/Lazy eye Macular degeneration Eye trauma Other
My	Mother Father Grandmother Grandfather Brother Sister Other	Has	Myopia Hyperopia Astigmatism Presbyopia Ambloyopia Corneal dystrophy Dry eyes Cataracts Glaucoma Diabetic Retinopathy Hypertensive Retinopathy Crossed/Lazy eye Macular degeneration Eye trauma Other

Do You Wear?:

Computer eyeglasses	Prescription Eyeglasses
Safety Glasses	Prescription Sunglasses
Sports Googles

HOW OLD ARE YOUR CURRENT EYEGLASSES

N/A 1 Year 2 Years More than 2 years Other

Contact Lens History:

Do You Wear Contact Lenses	Yes No Both Other	If Yes, What Brand	Acuvue 2 Acuvue 2 Colors Acuvue Advance Acuvue Oasys Acuvue Advance Ast Acuvue Oasys Ast Air Optix Air Optix Ast Air Optix MF Freshlook Colors ProClear Other	How Many Hours A Day Do You Wear Your Contacts	Less than 8 hours 9 to 12 hours More than 12 hours Sleep in contacts Other
How Often Do You Dispose Your Contacts	1 week 2 Weeks every month every 3 months every year Other	Do You Sleep Or Nap In Contacts	Never Occasionally Always Other	What Solutions Do You Use To Clean And Disinfect Your Contacts?	Do not know Generic Optifree Clearcare Other
Do You Wear UV Coated Sunglasses	yes no Other

General Health History

Last General Health Exam:

Never 1 Year ago 6 months ago 3 months ago Other

Doctors name:

Doctors Address:

Doctors Phone:

Please Check All Health Conditions That Apply To You:

Seasonal Allergies	Headaches
Arthritis	Heart Disease
HIV	Asthma
Hypertension	Cancer
Lung Disease	Diabetes
Vascular disease	Seizures

Family Members With Health Conditions:

My	Mother Father Grandfather Grandmother Brothers Sisters Other	Has	Seasonal Allergies Arthritis Asthma Cancer Diabetes Headaches Heart Disease HIV Hypertension Lung Disease Seizures Vascular Disease Other
My	Mother Father Grandfather Grandmother Brothers Sisters Other	Has	Seasonal Allergies Arthritis Asthma Cancer Diabetes Headaches Heart Disease HIV Hypertension Lung Disease Seizures Vascular Disease Other
My	Mother Father Grandfather Grandmother Brothers Sisters Other	Has	Seasonal Allergies Arthritis Asthma Cancer Diabetes Headaches Heart Disease HIV Hypertension Lung Disease Seizures Vascular Disease Other

Heve you had any Medical Surgeries

Medications

I take	None Other	For	Do not know Other
I take	None Other	For	Do not know Other
I take	None Other	For	Do not know Other

Please list any additional Medications	None Alphagan Alpahgan P Alrex Bepreve Genteal Lotemax Lumigan Maxitrol Optive OTC Allergy Pataday Patanol Prednisolone Refresh rewetting drops Systane Theratears Timolol Tobradex Travatan Z Vigamox Visine Xalatan Zylet Other
Medication Allergies
Non Brand Medications

Lifestyle Questionaire

These Questions Are Intended To Assist Us In Better Meeting Your Everyday Visual Needs.

How many hours do you spend on a computer if any?

None Less than an Hour More than an hour Other

Reading / Deskwork?

None Less than an Hour More than an hour Other

Outdoors

None Less than an Hour More than an hour Other

Nightime Driving?

None Less than an Hour More than an hour Other

Which Sports Do You Participate In?

None

Baseball/Softball

Basketball

Fishing

Football

Martial Arts

Golf

Hunting

Tennis

Ice Skating

Snow Skiing

Soccer

Swimming

Water Skiing

I want the style of my frames to be

Don't know Trendy Conservative Dressy Sporty Other

I want my frames to be made of

Metal Plastic Rimless Titanium Carbon Fiber Other

I want my lenses to be

Refection/Glare Free Transitions Thin Lite weight UV coated for protection Polarized Sunglasses to reduce glare Aspheric design so my eyes will not look magnified or minified Other

Has There Been A Time When You Wish You Were NOT Wearing Eyeglasses

If yes, would you like to know if you are a candidate for contact lenses

contact lenses Lasik both Other

Are you interested in colored contacts

Yes No Other

Social History

Alcohol Tobacco Drugs

Race:

Caucasian Asian Hispanic or Latino Black or African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Other

Preferred Language:

English Spanish Vietnamese French German Other

Review of Systems

General:	None Fever Weight Gain Weight Loss Other (ex. Fever, Weight loss, Weight gain, Fatigue)
Ear/Nose/Throat:	None Allergies Sinus Congestion Runny Nose Chronic Cough Dry Throat/Mouth Hearing Loss Other (ex. Allergies, Sinus, Cough, Dry Mouth / Throat)
Cardiovascular:	None High BP Heart Pain Vascular Disease Other (ex. High BP, Heart Surgery, Vascular Disease)
Respiratory:	None Asthma Bronchitis Emphysema COPD Other (ex. Asthma, Bronchitis, Emphysema, COPD)
Genitourinary:	None Painful Urination Frequent Urination Impotence Yellow Jaundice Kidney Stones Other (ex. Kidney Stones, Frequent Urination, Impotence)
Musculoskeletal:	None Arthritis Joint Pain Stiffness Swelling Cramps Other (ex. Athritis, Joint Pains, Head or Neck Injury)
Skin:	None Growths Rash Pimples Warts Other (ex. Growths, Rashes, Acne)
Neurological:	None Numbness, Paralysis Headache Seizures Migraines Other (ex. Headaches, Migraines, Seizures)
Psychiatric:	None Anxiety Depression Insomnia Other (ex. Depression, Anxiety, Insomnia)
Endocrine:	None Diabetes Hypothyroid Hyperthoyroid Other (ex. Thyroid, Diabetes)
Blood/Lymph:	None Anemia Bleeding Cholesterol Other (ex. Anemia, Cholesterol, Bleeding Problems)
Allergy/Immune:	None Sneezing Swelling Redness Itching Hives Lupus AIDS Other (ex. Seasonal Allergies, AIDS, Lupus)
Gastrointestinal:	None Diarrhea Constipation Ulcer Acid Reflux Other (ex. Diarrhea, Constipation, Ulcer, Reflux)

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