Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. 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. 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:

Vision Insurance

Insurance Information

Insurance Name:	None New Insurance No Name AARP AARP MEDICARE COMPLETE ACORDIA NATIONAL AETNA AETNA MEDICARE Allied Benefit Systems, Inc. By Aetna BANKERS LIFE & CASUALTY CO. BCBS BCBS MEDICARE CIGNA COMPBENEFITS EYEMED GEHA HUMANA HUMANA MEDICARE MEDICARE - Medicare MUTUAL OF OMAHA NONE NVA OTHER PHCS PREMIER EYE CARE RAILROAD MEDICARE - Railroad Medicare SPACECITY MACHINES STATE FARM SUPERIOR VISION TRICARE UHCV UMR UNICARE UNITED HEALTHCARE UNITED HEALTHCARE MEDICARE SOLUTIONS UnitedHealth VBA-VISION BENEFITS OF AMERICA VISION CARE PLAN VSP
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:

Primary Insurance

Insurance Information

Insurance Name:	None New Insurance No Name AARP AARP MEDICARE COMPLETE ACORDIA NATIONAL AETNA AETNA MEDICARE Allied Benefit Systems, Inc. By Aetna BANKERS LIFE & CASUALTY CO. BCBS BCBS MEDICARE CIGNA COMPBENEFITS EYEMED GEHA HUMANA HUMANA MEDICARE MEDICARE - Medicare MUTUAL OF OMAHA NONE NVA OTHER PHCS PREMIER EYE CARE RAILROAD MEDICARE - Railroad Medicare SPACECITY MACHINES STATE FARM SUPERIOR VISION TRICARE UHCV UMR UNICARE UNITED HEALTHCARE UNITED HEALTHCARE MEDICARE SOLUTIONS UnitedHealth VBA-VISION BENEFITS OF AMERICA VISION CARE PLAN VSP
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 No Name AARP AARP MEDICARE COMPLETE ACORDIA NATIONAL AETNA AETNA MEDICARE Allied Benefit Systems, Inc. By Aetna BANKERS LIFE & CASUALTY CO. BCBS BCBS MEDICARE CIGNA COMPBENEFITS EYEMED GEHA HUMANA HUMANA MEDICARE MEDICARE - Medicare MUTUAL OF OMAHA NONE NVA OTHER PHCS PREMIER EYE CARE RAILROAD MEDICARE - Railroad Medicare SPACECITY MACHINES STATE FARM SUPERIOR VISION TRICARE UHCV UMR UNICARE UNITED HEALTHCARE UNITED HEALTHCARE MEDICARE SOLUTIONS UnitedHealth VBA-VISION BENEFITS OF AMERICA VISION CARE PLAN VSP
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

Personal and Social History

Referred By:

Insurance Friend/Family Website/Internet Yellow Pages Walk-by/Drive-by Other

Family Patients:

Hobbies:

Arts and Crafts Baseball Basketball Fishing Horses Hunting Jogging Lawn Work None Outdoors Painting Photography Piano Pogs Reading Running Sailing Scuba Sewing Skiing Soccer Softball Swimming Tennis T.V. Video Games Wake Boarding Weights Woodworking Other

Interested In Contact Lenses?

Yes No Other

Ever Worn Contact Lenses?

Yes No Other

Type of CLs worn in past:

Disposables Extended Wear Gas Permeables Gas Perm Bifocals Gas Perm Bitorics Gas Perm FS Toric Monovision - Soft Monovision - Disposables Monovision - Gas Perm No CL Hx Soft Daily Wear Soft Torics Other

Occupation:

Employer:

Primary Vision Correction:

None Bifocals Contacts Contacts - Mono Progressives Single Vision Trifocals Other

Sunspecs?

Yes No Other

Medical Personal and Family History

Eye Hx: Sting, Burn, Itch, Surg.,Injury,Cats, Ambly.,Floaters, GL, Strab., Retinal

None Abrasion Blind Eye Blepheroplasty Cataract - OU Cataract - OD Cataract - OS Conjunctivitis Glaucoma IOL - OU IOL - OD IOL - OS Metal in Eye Ptosis Retinal Detach Weak Eye Lazy Eye Other

Eye Meds:

None Acular Artificial Tears Betoptic-S .25% Betoptic .5% Betagan Erythromycin FML FML Forte Gentamicin Neosporin Ocupress Pilo Gel Propine Polytrim Pred Mild Pred Forte Patanol Timoptic .25% Timoptic .5% Tobradex Voltaren None Xalatan Other

Primary Care Physician:

Systemic Meds:

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

Family Med History:

None Artheritis Cancer Diabetes I Diabetes II Hypertension Hypercholesterolmia Heart Dx Other

Family Eye History:

None Amblyopia Cataracts Glaucoma Macular Degeneration Retinal Detachment Weak Eye Lazy Eye Other

Medication and Seasonal Allergies:

NKDA NKA Codeine Erythromycin Iodine Pollen PCN Sulfa Seasonal Tetanus Other

NOTES/SOCIAL HISTORY

Social Hx: Denies any tobacco, alcohol and drug use Other

Review Of Systems

Review Of Systems

General:

Healthy Negative Weight Gain Weight Loss Other

Cardiovascular:

Negative Cardiovascular disease Hypertension Stroke Heart attack Congestive Heart Disease Heart Murmur Arrhythmia Heart Palpitation Arteriosclerosis Other

Respiratory:

Negative Asthma Lung Cancer Sleep Apnea COPD Sarcoidosis Bronchitis Other

Gastrointestinal:

Negative Crohn's Disease Hepatitis Colon Cancer Colitis Ulcers Acid Reflux Other

Muscles, Bones, Joints:

Negative Arthritis Rheumatoid Arthritis Myasthenia Gravis Fibromyalgia Osteoporosis Other

Skin:

Negative Skin cancer Acne Rosacea Lupus Eczema Psoriasis Other

Neurological:

Negative Headache Seizures Multiple Sclerosis Migraines Parkinson's Disease Dementia Other

Psychiatric:

Negative Anxiety Depression Insomnia Bipolar Attention Deficit Disorder Obsessive/compulsive Other

Endocrine:

Negative Diabetes type 1 Diabetes type 2 Borderline Diabetes Hyperthyroid Hypothyroid Gout Hormone Replacement Therapy Other

Blood/Lymph:

Negative Anemia Cholesterolemia Sickle Cell Other

Allergic/Immunologic:

Negative Lupus Hives HIV AIDS Sarcoidosis Sjogren's syndrome Seasonal allergies Environmental allergies Food allergies Other

Genitourinary:

Negative Pregnant Nursing Menopause Prostate Cancer Uterine Cancer Other

Disposition

Patient is pleasant and sociable. Other

Orientation

Patient is fully alert to time, place, and person. Other

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