Patient information

First name

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Last name

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Nickname

Pronoun

Address

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Address2

City

State

ZipCode

Home Phone

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Cell Phone

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Work Phone

Other Phone

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Preferred Contact Method

Birthday

SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Birth Sex

Male Female

Gender Identity

Marital Status

Misc/Guardian

Billing information

Is The Billing Address Different? Yes

Title

First

Last

Middle

Suffix

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Eye History

What is the main reason for your visit today?(examples: I need a diabetic eye exam, my eyes are dry, my vision is blurry with glasses or contacts, etc):

Please elaborate on any eye related concerns you'd like to bring up at your visit:

How do you use your eyes most of the day? Please describe your visual tasks (example: computer work for 6 hrs/day) and any visual needs for hobbies (example: I play sports and need to be able to track a ball well)

Patient Ocular History

Previous Injuries, Infections, Surgeries, Diseases:

Last Eye Exam

Eye Medications: (examples: retaine MGD drops)

Family Eye History

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

Macular Degen

Glaucoma

Retinal Detach

Blindness

Cataracts

Lazy/Crossed Eye

Primary vision correction

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Medical History

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Medical History:

Primary Care Provider

PCP Phone #

PCP Fax #

SYSTEMIC MEDS

Do you have diabetes?

Type

A1C

Blood sugar

Is your diabetes controlled?

Additional Meds No Medications

Over the Counter Medications

Vitamins

Drug Allergies

Height

Weight

PAST PATIENT MEDICAL HISTORY (HAs, Arthritis, Asthma, Diabetes, HBP, Heart, Infl. Bowel Dz, Seizures, Thyroid):

Injuries, Surgeries, Hospitalization

Pregnant or Nursing

IMMEDIATE FAMILY MEDICAL HISTORY (Diabetes, HBP, Heart Dz, Cancer, Athritis, Lupus, Kidney, Thyroid, Other):

Review Of Systems

General

Skin

Ear/Nose/Throat

Cardiovascular

Respiratory

Musculoskeletal

Psychiatric

Gastrointestinal

Endocrine

Blood/Lymph

Neurological

Genitourinary

Immune

Social History

Hobbies

Smoking Status

Type

How long

Alcohol Use

Type

How long

Recreational Drug use

Type

How long

Race

Ethnicity

Preferred Language

STD

SPEED QUESTIONNAIRE FOR DRY EYE

Frequency Legend: (rate on a scale of 3: 0 = Never, 1 = Tolerable, 2 = Often, 3 = Consistant)
Severity Legend: (rate on a scale of 4: 0 = No Problems, 1 = Tolerable, 2 = Uncomfortable, 3 = Bothersome, 4 = Intolerable)

Symptoms	Frequency of Symptoms	Severity of Symptoms
Dryness, Grittiness, Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

Please select if you have experienced symptoms:
Today
Within the past 72 hours
Within the past 3 months

Do you use eye drops and/or ointment?

If yes, which drops/ointment do you use?

Have you been told that you have blephartis?

Have you been treated for a stye?

Do you have fluctuating vision problems?(That can be corrected with blinking)

Financial Policy

Click here to read the Financial Policy

NOTICE OF PRIVACY PRACTICES

Click here to read the NOTICE OF PRIVACY PRACTICES

I acknowledge there is a 40 no show/cancel fee(If canceled less than 24 hour of appointment time)

E-Signature

By checking this box, I have read and agree to all of the above.

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Thank you!

Patient information

Billing information

Primary Vision Insurance

Primary Medical Insurance

Eye History

Family Eye History

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

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Medical History

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Medical History:

Review Of Systems

Social History