Online Patient Form

Demographics

Patient Information

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

Address:
City:		State/ZipCode	CA AL AK AZ AR 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 TX 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. Miss

Copy Address From Above
Address

City	State	ZipCode
	CA AL AK AZ AR 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 TX UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None AARP ADVENTIST HEALTH Adventist Health-LLUMC Murrieta Aetna Ameritas Anthem Blue Cross ANTHEM BLUE CROSS Blue Cross Blue Shield BLUE SHIELD OF CA Blue Shield of California Care Credit CIGNA HEALTHCARE EXCLUSIVE CARE Eye Med Vision Care HEALTH NET HMO HUMANA Inland Empire Health Plan Kaiser Permanente LA FIREMEN'S RELIEF ASSOCIATION Medi-cal Medical Eye Services Medicare Noridian GE Part V Met Life Molina PERSCARE Pinnacle Principal Insurance Risk Management Safeguard Scan Health Plan Spectera Optum Health Straight M-cal Superior Vision UFCWU UNITED HEALTHCARE Vision Benefits of America 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 Information

Insurance Name:	None AARP ADVENTIST HEALTH Adventist Health-LLUMC Murrieta Aetna Ameritas Anthem Blue Cross ANTHEM BLUE CROSS Blue Cross Blue Shield BLUE SHIELD OF CA Blue Shield of California Care Credit CIGNA HEALTHCARE EXCLUSIVE CARE Eye Med Vision Care HEALTH NET HMO HUMANA Inland Empire Health Plan Kaiser Permanente LA FIREMEN'S RELIEF ASSOCIATION Medi-cal Medical Eye Services Medicare Noridian GE Part V Met Life Molina PERSCARE Pinnacle Principal Insurance Risk Management Safeguard Scan Health Plan Spectera Optum Health Straight M-cal Superior Vision UFCWU UNITED HEALTHCARE Vision Benefits of America 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 Information

Insurance Name:	None AARP ADVENTIST HEALTH Adventist Health-LLUMC Murrieta Aetna Ameritas Anthem Blue Cross ANTHEM BLUE CROSS Blue Cross Blue Shield BLUE SHIELD OF CA Blue Shield of California Care Credit CIGNA HEALTHCARE EXCLUSIVE CARE Eye Med Vision Care HEALTH NET HMO HUMANA Inland Empire Health Plan Kaiser Permanente LA FIREMEN'S RELIEF ASSOCIATION Medi-cal Medical Eye Services Medicare Noridian GE Part V Met Life Molina PERSCARE Pinnacle Principal Insurance Risk Management Safeguard Scan Health Plan Spectera Optum Health Straight M-cal Superior Vision UFCWU UNITED HEALTHCARE Vision Benefits of America 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:

COVID

COVID-19 SCREENING
Within the last 14 days have you experienced any of the following symptoms:

NO YES
Fever
Cough
Shortness of breath or difficulty breathing
Chills
Repeated shaking with chills
Muscle pain
Sore throat
New loss of taste or smell
Have you traveled in the last 14 days?
Have you or a member of your household had
close contact with or cared for someone
diagnosed with COVID-19 in the last 14 days?
Have you or a member of your household had
close contact with or cared for someone with a presumptive
positive case of COVID-19 in the last 14 days?
Has anyone in your household been asked or required to
quarantine based on contact with a person who has a
confirmed or presumptive positive COVID-19 test result or
diagnosis, or have you been asked to quarantine?

Medical History

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

Chief Complaint

Review Of Systems

Family History	denies family history of medical eye problems ARMD (dry): father mother sibling grandparent aunt uncle ARMD (wet): father mother aunt uncle sibling grandparent CATARACT: father mother sibling grandparent aunt uncle GLAUCOMA: father mother sibling grandparent aunt uncle Other
Major Inj/Surg	denies history of major surguries / injuries Other
Constitutional	appetite loss equilibrium issues fatigue/malaise/lethargy flu/fever night sweats recent trauma sleeping pattern change weight change Other
Ear,Nose,Throat	chronic cough dental problems dry mouth/throat hearing loss nasal/sinus problems sleep apnea tinnitus vertigo Other
Cardiovascular	atherosclerosis atrial fibrillation bipass surgery bradycardia chest pain congestive heart failure coronary artery disease heart attack hypertension irregular heart beat low blood pressure tachycardia TIAs Other
Respiratory	asthma chronic cough COPD emphysema shortness of breath sleep apnea TB wheezing Other
Genitourinary	benign prostatic hyperplasia endometriosis erectile dysfunction incontinence overactive bladder STD urinary tract infection Other
Gastrointestinal	abdominal pain acid reflux Celiac disease constipation Crohn's disease diarrhea diverticulitis gallstones GERD hepatitis A hepatitis B hepatitis C IBS Other
Endocrine	pre-diabetes type 1 diabetes mellitus without complications type 1 diabetes mellitus with hyperglycemia type 2 diabetes mellitus without complications type 2 diabetes mellitus with hyperglycemia personal history of gestational diabetes Grave's disease hyperthyroid hypothyroid kidney disease kidney stones Other
Diabetes	personal history of gestational diabetes pre-diabetes type 1 diabetes mellitus with hyperglycemia type 1 diabetes mellitus without complications type 2 diabetes mellitus with hyperglycemia type 2 diabetes mellitus without complications Other
A1c	unknown to pt Other	YrDx
Musculoskeletal	ankylosing spondylitis carpal tunnel syndrome hip surgery myasthenia gravis osteoarthritis Other
Integumentary	acne acne rosacea basal cell dandruff eczema erythema gout melanoma psoriasis rash seborrheic / actinic keratosis warts Other
Neurological	Alzheimer's ADHD autism bipolar dementia fibromyalgia headaches migraine headaches multiple sclerosis muscle weakness Parkinson's disease personality changes speech problems tremors vertigo Other
Psychiatric	anger issues anxiety bipolar delusions dementia depression Down's syndrome epilepsy insomnia mood changes obsessive / compulsive paranoia schizoprenia substance abuse Other
Hemato/Lymph	anemia clotting disorder hemophilia hypercholesterolemia hypertriglyceridemia jaundice sarcoidosis temporal arteritis Other
Allergy/Immune	AIDS herpes simplex HIV hives lupus erythematosis medication allergy rheumatoid arthritis seasonal allergy shingles Other

ROS Summary

Ocular Surgery Summary

Ocular Problems Summary

PCP		Last Eye Dr
Med Ins		Vision Plan
MarStat	annulled divorced domestic partner interlocutory legally separated married never married single widowed Other	ReferredBy	Other
Occ/Grd	accountant architect attorney caregiver carpenter clerk/checker computer data entry computer/software industry construction/labor counselor custodian/maintenance daycare dentist draftsman driver education electrician electronic technician engineer financial services industry firefighter food services industry grocery industry hairdresser human resources interior design landscape architect machinist manager mechanic medical assistant nursing office manager optician painter paralegal pharmacist physician pilot plumber podiatrist police officer postal/mail carrier professor property management psychologist real estate industry restaurant industry sales secretary speech pathologist student teacher Other	Emp/Sch
Prt/Guar		LiveAlone	assisted living No nursing home Yes 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	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
Edu.	No Yes Other	Ethn	Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Other
Alcohol	None occasional social 1-2 drinks/day several drinks/day Other	Lang	patient declined to specify English 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 French 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 Spanish 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
Has HTN	Yes No Other

Vit/Supplements

None Multi-vitamins Vit A Vit B Complex Vit B12 Vit C Vit D Vit E biotin Calcium Fe Mg Mn Zn Biotears Fish Oil Flax Evening Primrose oil Borage oil Glucosamine Chondroitin MSM niacin CoQ10 zeaxanthin Lutein iCaps Lutein & Omega 3 Macula Complete Ocuvite / I-caps Preservision AREDS 2 Preservision Ginko-Biloba resveratrol St John's wort Red Yeast Rice Juice+ curcumin garlic green tea extract probiotic Stinging nettle Other

Meds today - No Meds

Abilify Accolate Accupril / Quinapril Accutane Acebutolol Aceon Acetaminophen Acetaminophen/Codeine Acetasol HC Acetylcysteine Acidolophus Aciphex Aciphex / rabeprazole Actiq Activella Actonel Actonel / risedronate Actonel W/Calcium Actoplus Met Actos Acular Ophthalmic Solution 5 mL Acular PF Ophthalmic Solution Acyclovir Adalat Adderall Adderall XR Advair Diskus Advate Advicor Advil Afinator Afrin Aggrenox Aircept Alacyclovir Alamast Ophthalmic Solution 10 mL Alavert Alaway Albuterol Albuterol Aerosol Albuterol Nebulizer Sol. Aldomet Alendronate Alesse Aleve Alfuzosin Alka-Seltzer Allclear Allegra Allegra-D Allegra / fexofenadine Aller-Tec AllerClear Allerest Allergy Shots AlleRx-D Oral Allopurinol Alocril Ophthalmic Solution 5 mL Alomide Ophthalmic Solution 10 mL Aloopurino Alora Alpha-Lipoic Acid Alphagan P Ophthalmic Solution Alprazolam Alrex Ophthalmic Suspension Altace Altace / ramipril Altoprev Altram Alvesco Am-Dry D Amantadine Amaryl Amaryl / glimepiride Ambien Ambien / zolpidem Amerge Ami-Tex LA Amiloride Aminopyridine Amiodarone Amitiza Amitriptyline Amlodipine Amlodipine-Benazerpril Amlodipino Ammonium Lactate 12% Amoxicillin Amoxicillin/Potassium Clavulanate Amoxil Amphetamine Mixed Salts Amphetamine/Dextroamphetamine Ampicillin Anastrazole Androderm Androgel Ansid Anthralin Cream Anti-oxidant w/ macular carotenoids Anti-oxidant w/o macular carotenoids Anzemet Apidra Apri Aranelle Arava Aricept Aricept / donepezil Arimidex Arimidex / Anastrozole Armour Thyroid Aromasin Artane Arthrotec Arythromyacian Asacol Asmanex Aspirin Astelin Asthmacort Astragalus Atacand Atacand / candesartan Atacand Hct Atenolol Atenolol/Chlorthalidone Ativan Atorvastatin Augmentin Augmentin XR Avalide Avandament Avandia Avandia / rosiglitazone Avapro Avapro / irbesartan Avastin Avelox Aviane Avista Avodart Avonex Axert Azasite Ophthalmic Solution Azathioprine Azelastine Azilect Azithromycin Azopt Ophthalmic Solution Azor Azulfidine B50 Baclofen Bactrim Bactroban Baraclude BCP Beconase Benazepril Benicar Bensoilproxide Bentyl Buspar Captopril Carbamazepine Casodex / bicalutamide Celebrex Celexa / celecoxib Cialis Cipro / ciprofloxacin citalopram Clarinex / desloratadine Clonidin Combivent / albuterol-ipratropium Coreg / carvedilol Coumadin / warfarin Cozaar / losartan Crestor Depakote Detrol / tolterodine Diclofenac Dilantin Diovan / valsartan Ditropan XL / oxybutynin Effexor / venlafaxine Evista / raloxifene Exelon / rivastigmine Flomax / tamsulosin Flonase / fluticasone Flovent / fluticasone Fosamax / alendronate furosemide gabapentin Glucophage / metformin Glucotrol / Glipizide Glyburide HCTZ Humulin / insulin hydrocodone-acetaminophen Hydrocortisone Hyzaar losartan Lanoxin / digoxin Lantus / insulin Lasix Lescol / fluvastatin Levaquin / levofloxacin levothyroxine Levoxyl Lexapro / escitalopram Lipitor / atorvastatin lisinopril Lotensin / benazepril Lotril / amlodipine-benazepril metformin Methlyprednisolone metoprolol Mobic / meloxicam Monpril / fosinopril Nasacort Nasonex / mometasone Neurontin / gabapentin Nexium / esomeprazole None Norvasc / amlodipine Novalog omeprazole Oxycodone Oxycontin / oxycodone Paxil / paroxetine Pepcid Plaquenil Plavix / clopidogrel Pletal / cilostazol Pravachol / pravastatin Prednisone Premarin / estrogen Prempro Prevacid / lansoprazole Prilosec / omeprazole Procar / finasteride Protonix / pantoprazole Proventil Prozac Risperdal / risperidone Ritalin Seroquel / quetiapine sertraline simvastatin Singulair / montelukast Synthroid / levothyroxine Tetracycline Topamax Toprol / metoprolol Tricor / fenofibrate Ultracet / tramadol-acetominophen Valium Viagra / sildenafil warfarin Wellbutrin / bupropion Xanax Zantac Zestril Zetia / ezetimibe Zithromax / azithromycin Zocor / simvastatin Zoloft / sertraline zolpidem Zyrtec Other

Allergies today - NKDA

Other

OTC Drops

none Refresh Optive Advanced Refresh Optive Sensitive Systane Balance Systane Gel Systane Ultra Theratears Visine Other

Pharmacy

Submit Data