Online Patient Forms

Demographics

How Did You Hear About Us? (Select One) Annual Postcard Google Yelp! Bing Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev. Fr. 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	Single Married Separated Divorced Widowed Unknown	Employer/School Name
Primary Doctor	No Doctor Assigned	Misc/Guardian

Preferred Language: English Spanish French Patient Declined to Specify

Ethnicity:  Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify   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

Billing Information

Is The Billing Address the Same?

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

Primary

Insurance Information

Insurance Name:	None AETNA Ambetter From Superior BCBS Blue Vision CHC CHIP CHC HIM CHC STAR CIGNA Davis Vision Eyemed Eyemed/Aetna HUMANA March Vision NVA Premier Eye Care Selfpay Spectera Superior TCH CHIP TCH STAR TCH STAR KIDS TMHP UHC 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 AETNA Ambetter From Superior BCBS Blue Vision CHC CHIP CHC HIM CHC STAR CIGNA Davis Vision Eyemed Eyemed/Aetna HUMANA March Vision NVA Premier Eye Care Selfpay Spectera Superior TCH CHIP TCH STAR TCH STAR KIDS TMHP UHC 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 Vision Issues For This Visit

Secondary Vision Issues For This Visit:

DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?
GENERAL: Fever, weight loss, weight gain, fatigue?
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury
SKIN: growths, rashes, acne
NEUROLOGICAL: Headaches, migraines, seizures
PSYCHIATRIC: Depression, Anxiety, Insomnia
ENDOCRINE: Thyroid, Diabetes
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, M.S., Lupus, HIV
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

PATIENT MEDICAL HISTORY

Please list any Injuries, Surgeries, Hospitalization

Pregnant Or Nursing: No Yes Unsure Not Pregnant but nursing Not Nursing but pregnant

Preferred Pharmacy: Location: Phone:

Primary Care Physician: Phone: Fax: Last Visit: 1 week 1 month 3 months 6 months 1 year 2 years

Reason For Visit: Annual Physical Visit for a specific problem Check up    List any Vitamins you take:

Please list any over the Counter medications:

Please list your current Prescription Medications: No Current Medications

Please list all drug allergies: No Known Drug Allergies

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 Cigaretts Chewing Tobacco Other How Long:

Alcohol: No Yes Occasionally Socially Other Type: None Beer Wine Hard Liquor Other How Long:

FAMILY MEDICAL HISTORY

Do you have a history of any of the following in your family? (Please select from the drop downs below.)
None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid

None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid


PATIENT OCULAR HISTORY

Please select if you have had any of the following: Itching Burning, Stinging Amblyopia Eye Injuries Eye Surgery Flashes Of Light Floaters Strabismus Cataracts Glaucoma Retinal Disorders None

Please select your current Eye Meds: None Pataday Patanol Latacaft Elestat Alaway Lotemax Alrex Refresh Systane Blink rewetting drops Visine Genteal Xalatan Alphagan Travatan Pred Forte Vigamox Cromolyn NA 4% Other

Last Eye Doctor: Last Eye Exam: 1 year 2 years 3 years over 3 years  

Primary Vision Correction:  None Glasses-Full Time Glasses-Readers Only Contacts - Soft RGPs PMMA

Type of CLs worn in past: None Disposable Conventional Colored RGP PMMA  Wear Time: 8 - 10 Hours All day Occ. Overnight Extended Disposal: 2 weeks monthly daily weekly yearly

FAMILY OCULAR HISTORY

Glaucoma: No Parents Sibling Grandparent Crossed / Lazy: No Parents Siblings Grandparent Retinal Detach: No Parents Siblings Grandparent Macular Degeneration: No Parents Siblings Grandparent Cataracts: No Parents Siblings Grandparent

DEMOGRAPHICS

Race: Patient Declined to Specify White Black or African American Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Other Race Ethnicity: Patient Declined to Specify Not Hispanic or Latino Hispanic or Latino Other Preferred Language: English French German Spanish Height Ft.: Inch: Weight Lbs:

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