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 #

Is the Billing Address Different?

Billing Information

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

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:

Primary

Insurance Information

Insurance Name:	None New Insurance New Insurance Advantica benefits Aetna Always Vision Amerigroup Medical Avesis Axis BlueCross BlueShield of Texas Century Health Care Cigna Compbenefits - Humana Vision Care Plan Davis Vision Entrust Eyecare for Kids Eyemed Vision Care Heritage Vision Plans, Inc Humana Humana Military- Tricare March Vision Medicaid TMHP Medicare Mes vision Molina Healthcare (Medical) National Vision Administrators Opticare Pan American Life Premier Eye Care - Wellcare Reliance Standard Self Pay Spectera, Inc Staffmark-First health Superior Vision Texans Plus HMO Texas Children Health Plan Tricare UMR United Healthcare VCP (Vision Care Plan) Vision Benefits of America Vision Service Plan Wellcare
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 Advantica benefits Aetna Always Vision Amerigroup Medical Avesis Axis BlueCross BlueShield of Texas Century Health Care Cigna Compbenefits - Humana Vision Care Plan Davis Vision Entrust Eyecare for Kids Eyemed Vision Care Heritage Vision Plans, Inc Humana Humana Military- Tricare March Vision Medicaid TMHP Medicare Mes vision Molina Healthcare (Medical) National Vision Administrators Opticare Pan American Life Premier Eye Care - Wellcare Reliance Standard Self Pay Spectera, Inc Staffmark-First health Superior Vision Texans Plus HMO Texas Children Health Plan Tricare UMR United Healthcare VCP (Vision Care Plan) Vision Benefits of America Vision Service Plan Wellcare
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:

Vision Plan

Insurance Information

Insurance Name:	None New Insurance New Insurance Advantica benefits Aetna Always Vision Amerigroup Medical Avesis Axis BlueCross BlueShield of Texas Century Health Care Cigna Compbenefits - Humana Vision Care Plan Davis Vision Entrust Eyecare for Kids Eyemed Vision Care Heritage Vision Plans, Inc Humana Humana Military- Tricare March Vision Medicaid TMHP Medicare Mes vision Molina Healthcare (Medical) National Vision Administrators Opticare Pan American Life Premier Eye Care - Wellcare Reliance Standard Self Pay Spectera, Inc Staffmark-First health Superior Vision Texans Plus HMO Texas Children Health Plan Tricare UMR United Healthcare VCP (Vision Care Plan) Vision Benefits of America Vision Service Plan Wellcare
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:

Other

Insurance Information

Insurance Name:	None New Insurance New Insurance Advantica benefits Aetna Always Vision Amerigroup Medical Avesis Axis BlueCross BlueShield of Texas Century Health Care Cigna Compbenefits - Humana Vision Care Plan Davis Vision Entrust Eyecare for Kids Eyemed Vision Care Heritage Vision Plans, Inc Humana Humana Military- Tricare March Vision Medicaid TMHP Medicare Mes vision Molina Healthcare (Medical) National Vision Administrators Opticare Pan American Life Premier Eye Care - Wellcare Reliance Standard Self Pay Spectera, Inc Staffmark-First health Superior Vision Texans Plus HMO Texas Children Health Plan Tricare UMR United Healthcare VCP (Vision Care Plan) Vision Benefits of America Vision Service Plan Wellcare
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:

Chief Complaint

Chief Complaint	Complete Eye Exam annual doctor directed diabetic eye exam burning Diabetic eye exam distance vision blurry dry eyes failed screening at school injury to eye itching loss of vision near vision blurry needs new glasses pain in eye red eye stinging vision blurry distance and near wants to be fitted for contacts glaucoma testing Lenses scratched Other
Secondary Complaints:

Review Of Ocular History

Ocular History:

None Itching Burning, Stinging Amblyopia Eye Injuries Eye Surgery Flashes Of Light Floaters Strabismus Cataracts Glaucoma Retinal Disorders Other

Eye Meds:

None Cromolyn NA 4% Visine Patanol Xalatan Travatan rewetting drops Elestat Vigamox Alphagan Refresh Theratears Genteal Pred Forte Lotemax Alrex Systane Blink Other

Primary Vision Correction:	None Glasses-Full Time Glasses-Readers Only Contacts - Soft RGPs PMMA Other	Back up specs?	Yes No Other	Getting new glasses?	Yes No Other
Last Eye Exam:	1 year 2 years 3 years Other	Doctor:	Never Doesn't Remember C. Toups Charrier Gonzales Inns Liu M. Toups Nguyen Tom EyeMasters Lens Crafters Pearl WalMart Other	Type of CLs worn in past:	None Disposable Conventional Colored RGP PMMA Other
Wear Time:	8 - 10 Hours All day Occ. Overnight Extended Other	Cleaner:	Optifree Clear Care Boston Renu Other	Disposal:	2 weeks monthly daily weekly yearly Other

Social History

Occupation:

Student Police officer Teacher Nurse Salesman Firefighter Engineer Other

Hobbies:

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

Do you drive?		If yes, do you have difficulty when driving?		If yes, describe
STD:	None Gonorrhea Syphilis Hepatitis HIV TB Other

Smoking Status	Current every day smoker Current some day smoker (not daily) Former smoker (no longer smokes) Heavy smoker (>10 cigs/day) Light smoker (<10 cigs/day) Never smoker (<100 cigs equiv) Smoker (current status unknown) Unknown if ever smoked Other	Type:	None Cigaretts Chewing Tobacco Other	How Long:
Alcohol:	No Yes Occasionally Socially Other	Type:	None Beer Wine Hard Liquor Other	How Long:
Illegal Drugs:	No Yes Other	Type:		How Long:

Meaningful Use / Patient Forms

Race:

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Patient Declined to Specify Other

Ethnicity:

Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Other

Preferred Language:

English Spanish French Patient Declined to Specify Abkhazian Afar Afrikaans Akan Albanian Amharic Arabic Aragonese Armenian Assamese Avaric Avestan Aymara Azerbaijani Bambara Bashkir Basque Belarusian Bengali Bihari languages Bislama Bokm?l, Norwegian), Norwegian Bokm?l Bosnian Breton Bulgarian Burmese Catalan; Valencian Central Khmer Chamorro Chechen Chichewa; Chewa; Nyanja Chinese Church Slavic; Old Slavonic; Church Slavonic; Old Bulgarian; Old Church Slavonic Chuvash Cornish Corsican Cree Croatian Czech Danish Divehi; Dhivehi; Maldivian Dutch; Flemish Dzongkha Esperanto Estonian Ewe Faroese Fijian Finnish Fulah Gaelic; Scottish Gaelic Galician Ganda Georgian German Greek, Modern (1453-) Guarani Gujarati Haitian; Haitian Creole Hausa Hebrew Herero Hindi Hiri Motu Hungarian Icelandic Ido Igbo Indonesian Interlingua (International Auxiliary Language Association) Interlingue; Occidental Inuktitut Inupiaq Irish Italian Japanese Javanese Kalaallisut; Greenlandic Kannada Kanuri Kashmiri Kazakh Kikuyu; Gikuyu Kinyarwanda Kirghiz; Kyrgyz Komi Kongo Korean Kuanyama; Kwanyama Kurdish Lao Latin Latvian Limburgan; Limburger; Limburgish Lingala Lithuanian Luba-Katanga Luxembourgish; Letzeburgesch Macedonian Malagasy Malay Malay Malayalam Maltese Manx Maori Maori Marathi Marshallese Mongolian Nauru Navajo; Navaho Ndebele, North; North Ndebele Ndebele, South; South Ndebele Ndonga Nepali Northern Sami Norwegian Norwegian Nynorsk; Nynorsk, Norwegian Occitan (post 1500) Ojibwa Oriya Oromo Ossetian; Ossetic Pali Panjabi; Punjabi Persian Polish Portuguese Pushto; Pashto Quechua Romanian; Moldavian), Moldovan Romansh Rundi Russian Samoan Sango Sanskrit Sardinian Serbian Shona Sichuan Yi; Nuosu Sindhi Sinhala; Sinhalese Slovak Slovenian Somali Sotho, Southern Sundanese Swahili Swati Swedish Tagalog Tahitian Tajik Tamil Tatar Telugu Thai Tibetan Tigrinya Tonga (Tonga Islands) Tsonga Tswana Turkish Turkmen Twi Uighur; Uyghur Ukrainian Urdu Uzbek Venda Vietnamese Volap?k Walloon Welsh Western Frisian Wolof Xhosa Yiddish Yoruba Zhuang; Chuang Zulu Other

Height:

FT

IN

Weight:

LBS

Medical History

Patient Medical History

Problems:

Good health Arthritis Asthma Diabetes HBP Headaches Heart Condition HX Of Drug/Alcohol Abuse Inflammatory Bowel Disease Smoking Seizure Disorder Thyroid Disease Preg "Now" Nursing Diagnosed As HIV+ Other

Injuries, Surgeries, Hospitalization:

Pregnant Or Nursing:

No Yes Unsure Other

Primary Care Physcian:

Doesn't Have One Doesn't Remember None Other

Last Visit:

1 week 1 month 3 months 6 months 1 year 2 years Other

Last Full Eye Exam:

OTC:

None Asprin Acetomenophin Ibuprofen Other

Vitamins:

None A E C Zinc Xanten Lutein Other

Medications	Drug Allergies

Family Medical History - Unknown Family History

Disease/Condition	Yes	No	Relationship To You	Disease/Condition	Yes	No	Relationship To You
Blindness				Diabetes
Crossed Eyes				Heart Disease
Cataract				High Blood Pressure
Glaucoma				Stroke
Macular Degeneration				Thyroid Disease
Retinal Detachment/Disease				Cancer

Review Of Systems

Review Of Systems: Do You Currently, Or Have Ever Had Any Problems In The Following Areas:

Eyes (Ocular Symptoms)
Disease/Condition	Yes	No
Eye Pain or Soreness
Fatigue/Tired Eyes
Foreign Body Sensation
Dryness/Gritty Feeling
Redness
Burning
Itching
Excess Watering
Mucous Discharge
Chronic Infection
Sties or Chalazion
Eyes (Visual Symptoms)
Disease/Condition	Yes	No
Squinting
Glare/Light Sensitivity
Distorted Vision/Halos
Double Vision
Loss of Vision
Loss of Side Visions
Blurred Vision
Flashes
Floaters

Constitutional
Disease/Condition	Yes	No
Fever
Weight Loss/Gain
Integumentary (Skin)
Disease/Condition	Yes	No
Metal Allergies
Ear, Nose, Mouth, Throat
Disease/Condition	Yes	No
Allergies/Hay Fever
Sinus Infections
Hearing Loss
Rosacea
Respiratory
Disease/Condition	Yes	No
Asthma
Chronic Bronchitis
Emphysema
Vascular/Cardiovascular
Disease/Condition	Yes	No
Heart Problems/Disease
Congestive Heart Failure
High Blood Pressure
High Cholesterol
Stroke

Gastrointestinal
Disease/Condition	Yes	No
Acid Reflux
Intestinal Problems
Liver Problems
Endocrine
Disease/Condition	Yes	No
Thyroid/Other Glands
Diabetes
Genitourniary
Disease/Condition	Yes	No
Genitals/Kidney/Bladder
Lymphatic/Hematologic
Disease/Condition	Yes	No
Anemia
Bleeding
Bones/Joints/Muscles
Disease/Condition	Yes	No
Rheumatoid Arthritis
Muscle Joint/Pain
Neurological
Disease/Condition	Yes	No
Headaches
Migraines
Seizures
Parkinsons's
Alzheimer's
Psychiatric
Disease/Condition	Yes	No
Immune System

Submit Data / Patient Signatures

Elective Screening Procedure

RETINAL IMAGING SCREENING- allows us to detect early signs of diabetic retinopathy, macular degeneration, retinal detachments and other threatening conditions. It adds to the medical record's written notes, an actual picture that can be viewed in the future.


3D WIDE WELLNESS SCREENING- A 3D cross-section scan through the layers of your retina. The images provide detailed mapping of each distinctive layer, many of which are beneath the surface and not visible to your doctor during routine examination. Images over the time can be compared for the early detection of potential eye diseases as well as tracking progression of existing condition.

I elect the $29 3D Wide OCT SCAN    I elect the $39.00 retinal imaging    I elect the $39 technology package for both    I decline these additional services   


A DILATED FUNDUS EXAM enables us to provide a more thorough ocular heath analysis. The side effects are blurred near vision and light sensitivity for about 3 - 4 hours. In some individuals, the distance may also be blurred.

YES, I want the dilation    NO, I do not want the dilation

Signature: (Initial)