Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev. 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:	Text Message Cell Phone Email Work Phone Home Phone Other Phone
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. 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:

Primary

Insurance Information

Insurance Name:	None AARP Medicare Complete Aetna Anthem Anthem Blue Cross Assistance League of Fullerton Avesis Blue Cross of California Blue Shield California Ironworker Field California Medicaid (Medi-Cal) Caremark Cigna Healthcare Coastal Vision Davis Vision Eyemed EyeMed Access Discount Guardian Medical Claim Department Health Partner Healthnet HealthSmart/Reaata Trust HMO Humana Vision Care Hydraflow ILWU-PMA Kaiser LHI Lions Club Medical Eye Services Medicare Metlife NVision Laser Eye Centers OptumHealth Pinnacle claim management INC Pricipal Life Ins Principal Life Insurance Co PRIVATE PAY Safeguard SCAN Health Plan Significa Smile Saver by Safeguard South Cali UFCW Souther California Lumber I W F Souther California Painting Drywall Southern California United Food Spectera Superior Tri Care West Region Tricare East UMR Union Roofers Health & Welfare United Health Care Vision Benefits of America VSP- Primary Eye Care VSP- Regional Network VSP-Access VSP-Advantage VSP-Signature VSP Choice VSP Exam Plus VSP Regional Network Plan
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 AARP Medicare Complete Aetna Anthem Anthem Blue Cross Assistance League of Fullerton Avesis Blue Cross of California Blue Shield California Ironworker Field California Medicaid (Medi-Cal) Caremark Cigna Healthcare Coastal Vision Davis Vision Eyemed EyeMed Access Discount Guardian Medical Claim Department Health Partner Healthnet HealthSmart/Reaata Trust HMO Humana Vision Care Hydraflow ILWU-PMA Kaiser LHI Lions Club Medical Eye Services Medicare Metlife NVision Laser Eye Centers OptumHealth Pinnacle claim management INC Pricipal Life Ins Principal Life Insurance Co PRIVATE PAY Safeguard SCAN Health Plan Significa Smile Saver by Safeguard South Cali UFCW Souther California Lumber I W F Souther California Painting Drywall Southern California United Food Spectera Superior Tri Care West Region Tricare East UMR Union Roofers Health & Welfare United Health Care Vision Benefits of America VSP- Primary Eye Care VSP- Regional Network VSP-Access VSP-Advantage VSP-Signature VSP Choice VSP Exam Plus VSP Regional Network Plan
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 AARP Medicare Complete Aetna Anthem Anthem Blue Cross Assistance League of Fullerton Avesis Blue Cross of California Blue Shield California Ironworker Field California Medicaid (Medi-Cal) Caremark Cigna Healthcare Coastal Vision Davis Vision Eyemed EyeMed Access Discount Guardian Medical Claim Department Health Partner Healthnet HealthSmart/Reaata Trust HMO Humana Vision Care Hydraflow ILWU-PMA Kaiser LHI Lions Club Medical Eye Services Medicare Metlife NVision Laser Eye Centers OptumHealth Pinnacle claim management INC Pricipal Life Ins Principal Life Insurance Co PRIVATE PAY Safeguard SCAN Health Plan Significa Smile Saver by Safeguard South Cali UFCW Souther California Lumber I W F Souther California Painting Drywall Southern California United Food Spectera Superior Tri Care West Region Tricare East UMR Union Roofers Health & Welfare United Health Care Vision Benefits of America VSP- Primary Eye Care VSP- Regional Network VSP-Access VSP-Advantage VSP-Signature VSP Choice VSP Exam Plus VSP Regional Network Plan
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

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Eye History

Reason for Visit:

Primary Reasons:	Secondary Reasons:

Do you currently have any of these symptoms?:	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?:	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:

1 year 2 years 3 years Other

Last Appointment Type

By Doctor:

Primary Vision Correction:

None Prescription Glasses Prescription Reading Glasses Soft Contacts Non-Prescription Reading Glasses Other

Do you:    Have back up glasses?

No Yes Other

Want new glasses?

No Yes Other

Want backup sunglasses?:

No Yes Other

Contact Lens Wearers only

Type of contacts worn in the past:

Cleaner:

Disposal:

Wear Time:

Medical History

Medications: No Meds Used	Over The Counter Medications:

Vitamins:	Drug Allergies: No Known Drug Allergies

Please describe any injuries or surgeries you have had:

Primary Care Physician:

Last Visit:

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

Reason:

Check up Annual Specific Other

Pregnant Or Nursing:

Yes No Unsure Other

Do you have any of these medical conditions?:

Diabetes:	No Yes	Year Diagnosed:
High Blood Pressure:	No Yes
High Cholesterol:	No Yes
Thyroid Conditions:	No Yes
Heart Conditions:	No Yes
Cancer:	No Yes

Other:

Family Medical History

Unknown family history

Does anyone in your family have any of these medical conditions?:

High Blood Pressure:	No Parents Siblings Grandparent Other	Diabetes:	No Parents Siblings Grandparent Other
Thyroid Conditions:	No Parents Siblings Grandparent Other	High Cholesterol:	No Parents Siblings Grandparent Other
Heart Conditions:	No Parents Siblings Grandparent Other	Other:
Cancer:	No Parents Siblings Grandparent Other

Family Eye History

Does anyone in your family have any of these eye conditions?:

Macular Degen:	No Parents Siblings Grandparent Other	Glaucoma:	No Parents Sibling Grandparent Other
Retinal Detach:	No Parents Siblings Grandparent Other	Cataracts:	No Parents Siblings Grandparent Other
Lazy/Crossed Eye:	No Parents Siblings Grandparent Other	Blindness:	No Parents Siblings Grandparent Other

Review of Systems

General:	None Fatigue Fever Loss of Appetite Weight Gain Weight Loss Developmental Disorders Other	Ear/Nose/Throat:	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:	None Acne Lupus Dermatitis Eczema Psoriasis Rosacea Skin Cancer Itching Other	Cardiovascular:	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:	None Asthma Cancer: lung Sleep Apnea Sarcoidosis COPD Emphysema Pneumonia Bronchitis Shortness of breath Wheezing Other	Musculoskeletal:	None Arthritis Osteoporosis Fibromyalgia Osteoarthritis Muscular Dystrophy Lupus Decreased range of motion Muscle cramps Pain/tenderness Stiffness Swelling Weakness Other
Psychiatric:	None Attention Deficit Disorder Anxiety Brain Damage (trauma) Panic Attacks Alzheimer's Disease Bi-polar Depression Insomnia Obsessive/Compulsive Paranoia Suicidal Violence Other	Gastrointestinal:	None Acid Reflux Crohn's disease Gastric reflux (GERD) IBS Ulcer Gall bladder problems Jaundice Hepatitis Sarcoidosis Cancer: colon Cancer: Liver Other
Endocrine:	None Crohn's disease Diabetes Type 1 Diabetes Type 2 Diabetes Suspect Hypothyroid Hyperthyroid Gout Hormone Replacement Therapy Other	Blood/Lymph:	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:	None Multiple Sclerosis Seizure Disorder Parkinson's Disease Brain 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:	None Amenorrhea Menopause Impotence Jaundice Uterine Cancer Prostate Cancer Kidney Stones Pregnant Nursing Syphilis Prostate Problems Bladder Infections STD- herpetic STD- chlamydia Other
Immune:	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

Social History

Hobbies:

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

Smoking Status:	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:	None Cigarettes Chewing Tobacco Other	How Long:
Alcohol Use:	No Yes Occasionally Socially Other	Type:	None Beer Wine Hard Liquor Other	How Long:
Illegal Drug Use:	No Yes Other	Type:		How Long

Race:	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:	Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Other	Preferred Language:	English French German Spanish Other
STD	None Gonorrhea Syphilis Hepatitis HIV TB

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