Medical Insurance NameMedical Insurance ID#Primary Insurance Holder First NamePrimary Insurance Holder Last NamePrimary Insurance Holder DOBMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Primary Insurance Holder SS#Do you have secondary insurance?YesNoused for conditional logicSecondary Insurance NameSecondary Insurance ID#Secondary Insurance Holder First NameSecondary Insurance Holder Last NameSecondary Insurance Holder DOBMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Secondary Insurance Holder SS#end conditional logic sectionPatient Name* First Last Patient D.O.B.*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Patient Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Patient Email Address*Patient Email Address Confirmation*Patient Cell Phone*Patient Alternate Phone*Primary Care Doctor NamePrimary Care Doctor PhoneSpecialist Care Doctor NameSpecialist Care Doctor PhoneDo you drive more than 5 hours a day?YesNoDo you work on a computer more than 5 hours a day?YesNoDo your contact lenses feel dry after 8 hours of wear?YesNoAre you pregnant and/or nursing?YesNoAre you receiving radiation treatment?YesNoAre you receiving chemotherapy?YesNoAre you taking Chloroquine, Hydroxychloroquine, Plaquenil?YesNoAre you taking Amiodarone?YesNoAre you taking Gilenya (fingolimod)?YesNoList of allergies and allergic reactions to medications, foods, latex, tape, I.V. and/or dyes?List of current medications you're taking, and the conditions they are treating?List of body injuries, surgeries, and/or hospitalizations?List of eye injuries, surgeries, and/or problems?Have you ever been exposed or infected with Gonorrhea, Syphilis, Herpes, Hepatitis, HIV (Aids)?YesNoTobacco Use?Don't SmokeFormer SmokerCurrent Some Day SmokerCurrent Every Day SmokerAlcohol?Don't DrinkSocial Use Only1-2 Drinks DailyAlcohol DependenceRecreational Drugs?Don't UseMarijuanaMethCocaineCrackHeroinAre any of these conditions in your family? Glaucoma RelationGrandmotherGrandfatherMomDadSibling Macular Degeneration RelationGrandmotherGrandfatherMomDadSibling Diabetes RelationGrandmotherGrandfatherMomDadSibling Heart Disease RelationGrandmotherGrandfatherMomDadSibling High Blood Pressure RelationGrandmotherGrandfatherMomDadSibling Retinal Detachment RelationGrandmotherGrandfatherMomDadSibling Thyroid Disease RelationGrandmotherGrandfatherMomDadSibling Blindness RelationGrandmotherGrandfatherMomDadSibling Cataract RelationGrandmotherGrandfatherMomDadSibling Crossed Eyes RelationGrandmotherGrandfatherMomDadSibling Arthritis RelationGrandmotherGrandfatherMomDadSibling Cancer RelationGrandmotherGrandfatherMomDadSibling Kidney Disease RelationGrandmotherGrandfatherMomDadSibling Lupus RelationGrandmotherGrandfatherMomDadSiblingDo you currently, or have you ever had any problems in the following areas?Fever, Weight loss/gainYesNoSkin ProblemsYesNoHeadachesYesNoMigrainesYesNoSeizuresYesNoLoss of VisionYesNoBlurred VisionYesNoDistorted Vision/HalosYesNoLoss of Side VisionYesNoDouble VisionYesNoEye DrynessYesNoEye Mucous DischargeYesNoEye RednessYesNoEye Sandy or Gritty FeelingYesNoEye ItchingYesNoEye BurningYesNoEye Foreign Body SensationYesNoEye Excess Tearing/WateringYesNoGlare/Light SensitivityYesNoEye Pain or SorenessYesNoChronic Infection of Eye or LidYesNoStyes or ChalazionYesNoFlashes/Floaters in VisionYesNoTired EyesYesNoThyroid/Other GlandsYesNoAllergic/ImmunologicYesNoPsychiatricYesNoAllergies/Hay FeverYesNoSinus CongestionYesNoRunny NoseYesNoPost-Nasal DripYesNoChronic CoughYesNoDry Throat/MouthYesNoAsthmaYesNoTuberculosisYesNoChronic BronchitisYesNoEmphysemaYesNoDiabetesYesNoHeart PainYesNoHeart MurmursYesNoHigh Blood PressureYesNoVascular DiseaseYesNoHepatitis/Other Liver DiseaseYesNoDiarrheaYesNoConstipationYesNoUlcersYesNoGenitals/Kidney/Bladder DiseaseYesNoRheumatoid ArthritisYesNoMuscle PainYesNoJoint PainYesNoAnemiaYesNoBleeding ProblemsYesNoAny other medical history not listed?Great job! One more step. Use your phone camera to photograph the front and back of your medical insurance card. If you are on a desktop you can easily attach the image.FrontBack