Medical Insurance Name Medical Insurance ID# Primary Insurance Holder First Name Primary Insurance Holder Last Name Primary Insurance Holder DOBMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Primary Insurance Holder SS# Do you have secondary insurance? Yes No Hiddenused for conditional logicSecondary Insurance Name Secondary Insurance ID# Secondary Insurance Holder First Name Secondary Insurance Holder Last Name Secondary Insurance Holder DOBMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Secondary Insurance Holder SS# Hiddenend 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 Name Primary Care Doctor Phone Specialist Care Doctor Name Specialist Care Doctor Phone Do you drive more than 5 hours a day? Yes No Do you work on a computer more than 5 hours a day? Yes No Do your contact lenses feel dry after 8 hours of wear? Yes No Are you pregnant and/or nursing? Yes No Are you receiving radiation treatment? Yes No Are you receiving chemotherapy? Yes No Are you taking Chloroquine, Hydroxychloroquine, Plaquenil? Yes No Are you taking Amiodarone? Yes No Are you taking Gilenya (fingolimod)? Yes No List 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)? Yes No Tobacco Use? Don't Smoke Former Smoker Current Some Day Smoker Current Every Day Smoker Alcohol? Don't Drink Social Use Only 1-2 Drinks Daily Alcohol Dependence Recreational Drugs? Don't Use Marijuana Meth Cocaine Crack Heroin Are 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/gain Yes No Skin Problems Yes No Headaches Yes No Migraines Yes No Seizures Yes No Loss of Vision Yes No Blurred Vision Yes No Distorted Vision/Halos Yes No Loss of Side Vision Yes No Double Vision Yes No Eye Dryness Yes No Eye Mucous Discharge Yes No Eye Redness Yes No Eye Sandy or Gritty Feeling Yes No Eye Itching Yes No Eye Burning Yes No Eye Foreign Body Sensation Yes No Eye Excess Tearing/Watering Yes No Glare/Light Sensitivity Yes No Eye Pain or Soreness Yes No Chronic Infection of Eye or Lid Yes No Styes or Chalazion Yes No Flashes/Floaters in Vision Yes No Tired Eyes Yes No Thyroid/Other Glands Yes No Allergic/Immunologic Yes No Psychiatric Yes No Allergies/Hay Fever Yes No Sinus Congestion Yes No Runny Nose Yes No Post-Nasal Drip Yes No Chronic Cough Yes No Dry Throat/Mouth Yes No Asthma Yes No Tuberculosis Yes No Chronic Bronchitis Yes No Emphysema Yes No Diabetes Yes No Heart Pain Yes No Heart Murmurs Yes No High Blood Pressure Yes No Vascular Disease Yes No Hepatitis/Other Liver Disease Yes No Diarrhea Yes No Constipation Yes No Ulcers Yes No Genitals/Kidney/Bladder Disease Yes No Rheumatoid Arthritis Yes No Muscle Pain Yes No Joint Pain Yes No Anemia Yes No Bleeding Problems Yes No Any 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.FrontMax. file size: 32 MB.BackMax. file size: 32 MB.