Evergreen Eye Care Online Patient Form

Demographics

Patient Information

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

Address:
City:		State/ZipCode	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 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

Is the Billing Address Different?

Billing Information

Address Same As Above

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

Address

City	State	ZipCode
	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 TX UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Medical History

PERSONAL HISTORY
Height Ft In   Weight
Allergies/Alerts:
List all medications you are currently taking (including any OTC/vitamins):

Do you have a history of any of the following?

SET ALL TO NO	YES	NO
Cataracts
Eye Turn (Strabismus)
Glaucoma
Keratoconus
Lazy Eye (Amblyopia)
Macular Degeneration
Retinal Detachment
Allergies/Hay fever
Arthritis
Asthma
Diabetes
High blood pressure
Migraines
Stroke
Thyroid problems

 

 


    


  

  

 



  
 

FAMILY HISTORY Family history is unknown/adopted
Any history of the following in any family members (parents, grandparents, siblings,children)?

SET ALL TO NO	Yes	No	Relationship To Patient
Poor Vision			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Blindness			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Eye turn (Strabismus)			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Lazy Eye (Amblyopia)			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Glaucoma			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Cataracts			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Macular Degeneration			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Retinal Detachment/Disease			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Cancer			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Diabetes			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
High Blood Pressure			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Stroke			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Thyroid Disease			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather
Other Inherited Disease			Mother Father Sister Brother Aunt Uncle Grandmother Grandfather

  
   
    
    



 
    




      





     

    
If yes, what disease?

SOCIAL HISTORY (confidential) 
How often do you smoke/use tobacco products? Never Occasionally Daily
How often do you consume alcohol: Never Occasionally Daily

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