Online Patient Form
After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!
Patient Information
Title:
Select
Mr.
Mrs.
Ms.
Dr.
Rev.
First
Last
MI:
Suffix:
Nickname:
Address:
Apt/Suite #:
City:
State:
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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
Zip Code:
Home Phone:
Work Phone:
Other Phone:
Alerts:
Cell Phone:
Contact Method:
Select
Home Phone
Work Phone
Cell Phone
Other Phone
Text Message
Email
SSN
Email
Birthday
Occupation
Sex
Male
Female
F
Employment Status
Employed
Full-Time Student
Part-Time Student
Marital Status
Select
Annulled
Divorced
Domestic partner
Interlocutory
Legally Separated
Married
Never Married
Polygamous
Widowed
Employer/School
Misc/Guardian
Billing Information
Is The Billing Address the Same?
Yes
Title:
Select
Mr.
Mrs.
Ms.
Dr.
Rev.
First:
Last:
MI:
Suffix:
Address:
Apt/Suite #:
City:
State:
Select
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
Zip Code:
Home Phone:
Work Phone:
Primary Insurance
Insurance Name:
Select
None
New Insurance
Aetna
Blue Cross Blue Shield MCR Advantage
Blue CrossBlue Shield
BTT
Care Credit
Care Improvement Plus
City Of Bridgeport
Devon Safety
DMEPOS CGS
Enlink
Enlink
EyeMed
Golden Rule UHC
Humana
Lions Club
Medicaid
Medicare
MEDICARE REPLACEMENT PLANS - Medicare Replacement
Railroad Medicare - Railroad Medicare
Rehabilitative Services
Supplement/medigap
UHC/Care Improv Plus
United Health Care
VSP
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 Name:
Select
None
New Insurance
Aetna
Blue Cross Blue Shield MCR Advantage
Blue CrossBlue Shield
BTT
Care Credit
Care Improvement Plus
City Of Bridgeport
Devon Safety
DMEPOS CGS
Enlink
Enlink
EyeMed
Golden Rule UHC
Humana
Lions Club
Medicaid
Medicare
MEDICARE REPLACEMENT PLANS - Medicare Replacement
Railroad Medicare - Railroad Medicare
Rehabilitative Services
Supplement/medigap
UHC/Care Improv Plus
United Health Care
VSP
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
Insurance Name:
Select
None
New Insurance
Aetna
Blue Cross Blue Shield MCR Advantage
Blue CrossBlue Shield
BTT
Care Credit
Care Improvement Plus
City Of Bridgeport
Devon Safety
DMEPOS CGS
Enlink
Enlink
EyeMed
Golden Rule UHC
Humana
Lions Club
Medicaid
Medicare
MEDICARE REPLACEMENT PLANS - Medicare Replacement
Railroad Medicare - Railroad Medicare
Rehabilitative Services
Supplement/medigap
UHC/Care Improv Plus
United Health Care
VSP
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:
Primary Reasons:
Medications:
Over The Counter Medications:
No Meds Used
No Known Drug Allergies
Vitamins:
Drug Allergies:
Please describe any injuries or surgeries you have had:
Primary Care Physician:
Last Visit:
Select
1 week
1 month
3 months
6 months
1 year
2 years
greater than 3 years
Other
Reason:
Select
Check up
Annual
Specific
Other
Pregnant Or Nursing:
Select
No
Yes
Unsure
Other
Recent Tetanus Shot:
Select
Yes
No
Recent Flu Immunization:
Select
Yes
No
Do you have any of these medical conditions? If yes, please describe:
Diabetes:
Year Diagnosed:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:
Family Medical History
Unknown family history
Does anyone in your family have any of these medical conditions? If yes, please describe:
Diabetes:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:
Eye History
Do you currently have any of these symptoms?:
Select
None
Itching
Burning, Stinging
Red
Floaters
Flashes Of Light
Eye Injuries
Eye Surgery
Amblyopia
Strabismus
Cataracts
Glaucoma
Retinal Disorders
Other
Do you take any of these eye medications?:
Select
None
Cromolyn NA 4%
Visine
Patanol
Xalatan
Travatan
rewetting drops
Elestat
Vigamox
Alphagan
Refresh
Theratears
Genteal
Pred Forte
Lotemax
Alrex
Systane
Blink
Other
Have you had any eye surgeries? Please describe:
Last Eye Exam:
Select
1 year
2 years
3 years
Other
By Doctor:
Primary Vision Correction:
Select
None
Prescription Glasses
Prescription Reading Glasses
Soft Contacts
Non-Prescription Reading Glasses
Other
Have back up glasses?
Select
No
Yes
Other
Want new glasses?:
Select
Yes
No
Want backup sunglasses?:
Select
Yes
No
Contact Lens Wearers only
Type of contacts worn in the past:
Cleaner:
Disposal:
Wear Time:
Family Eye History
Macular Degen:
Select
No
Parents
Siblings
Grandparent
Other
Glaucoma:
Select
No
Parents
Sibling
Grandparent
Other
Retinal Detach:
Select
No
Parents
Siblings
Grandparent
Other
Cataracts:
Select
No
Parents
Siblings
Grandparent
Other
Lazy/Crossed Eye:
Select
No
Parents
Siblings
Grandparent
Other
Blindness:
Select
No
Parents
Siblings
Grandparent
Other
Review of Systems
General:
Select
None
Fatigue
Fever
Loss of Appetite
Weight Gain
Weight Loss
Developmental Disorders
Other
Ear/Nose/Throat:
Select
None
Neck Problems
Sinus Problems
Sore Throat (Recent)
Headache
Morning Headaches
Migraine Headache
Cluster Headache
Hearing Loss
Tinnitus
Congestion
Dry throat / mouth
Sleep Apnea
Other
Skin:
Select
None
Acne
Lupus
Dermatitis
Eczema
Psoriasis
Rosacea
Skin Cancer
Itching
Other
Cardiovascular:
Select
None
Congestive Heart Disease
Cardiovascular Disease
High Cholesterol
Hypertension
Arrhythmia
Heart Murmur
Heart Palpitation
Chest Pain
Arteriosclerosis
Coagulation Disorder
Mitral Valve Prolapse
Low Blood Pressure
Other
Respiratory:
Select
None
Asthma
Cancer: lung
Sleep Apnea
Sarcoidosis
COPD
Emphysema
Pneumonia
Bronchitis
Shortness of breath
Wheezing
Other
Musculoskeletal:
Select
None
Arthritis
Osteoporosis
Fibromyalgia
Osteoarthritis
Muscular Dystrophy
Lupus
Decreased range of motion
Muscle cramps
Pain/tenderness
Stiffness
Swelling
Weakness
Other
Psychiatric:
Select
None
Attention Deficit Disorder
Anxiety
Brain Damage (trauma)
Panic Attacks
Alzheimer's Disease
Bi-polar
Depression
Insomnia
Obsessive/Compulsive
Paranoia
Suicidal
Violence
Other
Gastrointestinal:
Select
None
Acid Reflux
Crohn's disease
Gastric reflux (GERD)
IBS
Ulcer
Gall bladder problems
Jaundice
Hepatitis
Sarcoidosis
Cancer: colon
Cancer: Liver
Other
Endocrine:
Select
None
Crohn's disease
Diabetes Type 1
Diabetes Type 2
Diabetes Suspect
Hypothyroid
Hyperthyroid
Gout
Hormone Replacement Therapy
Other
Blood/Lymph:
Select
None
Anemia
Hx of Significant Blood Loss
Hematologic Disorder
Sickle Cell Disorder
Breast Carcinoma
Lymph Node Disease
Temporal Arthritis
Cuts slow to clot
Easy bruising
Other
Neurological:
Select
None
Multiple Sclerosis
Seizure Disorder
Parkinson's Disease
Brian Tumor
Bells Palsy
Dyslexia
Headache
Balance problems
Vertigo
Tremors
Changes in senses
Dementia
Memory problems
Muscle weakness
Numbness, paralysis
Personality changes
Speech problems
Other
Genitourinary:
Select
None
Amenorrhea
Menopause
Impotence
Jaundice
Uterine Cancer
Prostate Cancer
Kidney Stones
Pregnant
Nursing
Syphilis
Prostate Problems
Bladder Infections
STD- herpetic
STD- chlamydia
Other
Immune:
Select
None
Seasonal allergies
Environmental allergies
Food allergies
Drug allergies (please specify)
Sjogren's syndrome
AIDS
Herpes Simplex
HIV Simplex
Mononucleosis
Tuberculosis
Cytomegalovirus Infection
Herpes Zoster
Lyme Disease
Sarcoidosis
Syphilis
Hives
Itching
Mild allergy symptoms
Severe allergy symptoms
Swelling
Other
Orientation:
None
Oriented x 3
Other
Mood Affect:
None
Normal affect/mood
Agitated
Anxious
Depressed
Other
Social History
Hobbies:
Select
None
Art
Baseball
Astronomy
Boating
Basketball
Cooking
Crafts
Dancing
Diving
Football
Fishing
Golf
Gardening
Horseback Riding
Hunting
Models
Needlepoint
Painting
Photography
Piano
Reading
Running
Roller Blading
Softball
Sewing
Skiing
Soccer
Swimming
Tennis
Video Games
Woodworking
Other
STD's:
Select
None
Gonorrhea
Syphilis
Hepatitis
HIV
TB
Other
Smoking Status:
Select
Never smoker (<100 cigs equiv)
Former smoker (no longer smokes)
Current some day smoker (not daily)
Light smoker (<10 cigs/day)
Heavy smoker (>10 cigs/day)
Smoker (current status unknown)
Current every day smoker
Unknown if ever smoked
Other
Type:
Select
None
Cigarettes
Chewing Tobacco
Other
How Long:
Alcohol Use:
Select
No
Yes
Occasionally
Socially
Other
Type:
Select
None
Beer
Wine
Hard Liquor
Other
How Long:
Illegal Drug Use:
Select
No
Yes
Other
Type:
How Long:
Race:
Select
White
Black or African American
Asian
Patient Declined to Specify
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Other Race
Other
Ethnicity:
Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Patient Declined to Specify
Other
Preferred Language:
Select
English
French
German
Spanish
Other
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