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.

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

Insurance Information

Insurance Name:	None Aetna Ambetter (Superior) Amerigroup BCBS BCBS STAR Kids BCBS STAR/CHIP Cash Pay Celtic Healthy Texas CHIP (Superior) Community First Davis Vision Dell Children's Health Plan Eyemed Groupon Humana Health IdealCare (Sendero) Medicaid (TMHP) Medicare Spectera STAR (Superior) STAR Health (Superior) Star Kids (Superior) Superior Vision United HealthCare 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 Aetna Ambetter (Superior) Amerigroup BCBS BCBS STAR Kids BCBS STAR/CHIP Cash Pay Celtic Healthy Texas CHIP (Superior) Community First Davis Vision Dell Children's Health Plan Eyemed Groupon Humana Health IdealCare (Sendero) Medicaid (TMHP) Medicare Spectera STAR (Superior) STAR Health (Superior) Star Kids (Superior) Superior Vision United HealthCare 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:

Tertiary Insurance

Insurance Information

Insurance Name:	None Aetna Ambetter (Superior) Amerigroup BCBS BCBS STAR Kids BCBS STAR/CHIP Cash Pay Celtic Healthy Texas CHIP (Superior) Community First Davis Vision Dell Children's Health Plan Eyemed Groupon Humana Health IdealCare (Sendero) Medicaid (TMHP) Medicare Spectera STAR (Superior) STAR Health (Superior) Star Kids (Superior) Superior Vision United HealthCare 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

Chief Complaint

Exam Type

Exam Exam with CL Fit Emergency Visit Rx Check Contact Follow-up Dilation Pressure Check Other

Reason For Visit

Allergies (non-drug) - No known drug allergies

Medications (OTC) - No Current Medications

Ocular History

Surgeries/Injuries

Smoking Status

Unknown if ever smoked Never smoked Former smoker Light Smoker Heavy Smoker Other

Alcohol use

Not drinker Occasional drinker Every day drinker Other

Rec Drugs

No rec drugs Previous drug user Current drug user Other

Drives?

Drives Doesn't drive Other

Pregnant or Nursing

Not nursing/pregnant Nursing/pregnant 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

Personal Medical History

OPHTHALMIC

No	Vision Loss
No	Blurry Vision
No	Distorted Vision
No	Dry Eyes
No	Redness
No	Discharge
No	Double Vision
No	Retinal Detachment
No	Gritty Feeling
No	Itching
No	Excess Watering
No	Light Sensitvity
No	Burning
No	Eye Pain
No	DM Retinopathy
No	Glaucoma
No	Infection
No	Stie
No	Flashes
No	Floaters
No	Tired Eyes
No	Cataracts
No	Macular Degeneration

GASTROINTESTINAL

No	Colitis
No	Crohns Disease
No	Constipation
No	Ulcers
No	Diarrhea

CONSTITUTIONAL

No	Fever
No	Weight Loss / Gain
No	Fatigue
No	Trauma

SKIN

No	Eczema
No	Rosacea
No	Psoriasis

NEUROLOGICAL

No	Headaches
No	Migraines
No	Seisures
No	Multiple Sclerosis

ENDOCRINE

No	Type 1 Diabetes
No	Type 2 Diabetes
No	Thyroid Dysfunction
No	Hormonal Dysfunction

RESPIRATORY

No	Asthma
No	Bronchitis
No	Emphysema

CARDIOVASCULAR

No	Heart Disease
No	High Blood Pressure
No	High Cholesterol

EAR / NOSE / THROAT

No	Allergies
No	Sinus Congestion
No	Dry Mouth

ALLERGIC / IMMUNE

No	Drug Allergies
No	Seasonal Allergies
No	Arthritis

LYMPH / BLOOD

No	Anemia
No	Bleeding Problems
No	Leukemia

MUSCULOSKELETAL

No	Fibromyalgia
No	Osteoarthritis
No	Ankylosing Spond

GENITOURINARY

No	Kidney Problems
No	Bladder Problems
No	STD's

Family Medical History

Condition	Relative
Blindness	None Grandparent Parent Sibling Aunt/Uncle Child Unknown Other
Cataracts	None Grandparent Parent Sibling Aunt/Uncle Child Unknown Other
Macular Degeneration	None Grandparent Parent Sibling Aunt/Uncle Child Unknown Other
Glaucoma	None Grandparent Parent Sibling Aunt/Uncle Child Unknown Other
Retinal Detachment	None Grandparent Parent Sibling Aunt/Uncle Child Unknown Other

Condition	Relative
Cancer	None Grandparent Parent Sibling Aunt/Uncle Child Unknown Other
Diabetes	None Grandparent Parent Sibling Aunt/Uncle Child Unknown Other
Heart Disease	None Grandparent Parent Sibling Aunt/Uncle Child Unknown Other
Thyroid Disease	None Grandparent Parent Sibling Aunt/Uncle Child Unknown Other
Crossed Eyes	None Grandparent Parent Sibling Aunt/Uncle Child Unknown Other

Condition	Relative
High Blood Pressure	None Grandparent Parent Sibling Aunt/Uncle Child Unknown Other
Kidney Disease	None Grandparent Parent Sibling Aunt/Uncle Child Unknown Other
Arthritis	None Grandparent Parent Sibling Aunt/Uncle Child Unknown Other
Lupus	None Grandparent Parent Sibling Aunt/Uncle Child Unknown Other

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