Online Patient Forms

Patient information

First name

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Last name

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Nickname

Birth Sex

Male Female

Address

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Apt/Suite #

City

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State

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Zip Code

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Cell Phone

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Home Phone

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Preferred Contact Method

Birthday

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SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Pronoun

Gender Identity

Marital Status

Misc/Guardian

Billing information

Is The Billing Address Different? Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Please choose from the menu options or select the option to type in your own text. Thank you!

Visual History

VISUAL NEEDS HISTORY

Date

Nickname

Last Eye Exam

Age

Insurance #1

Insurance #2

Location of Last Eye Exam:

Hobbies

Race

Preferred Language

Physician's Name:

Preferred Pharmacy

Glasses Pair 1:

Glasses Pair 2:

Glasses Pair 3:

Glasses Pair 4:

Glasses Pair 5:

Glasses Prescription Up To Date?

MEDICAL EYE HISTORY

No Changes To Medical History

Have You Been Diagnosed With Any Of The Following Conditions?

Eye Turn (Strabismus):

Keratoconus:

Low Macular Pigment Density (MPOD):

Diabetic Retinopathy:

Blepharitis:

Amblyopia (Lazy Eye):

Retinal Hole:

Epiretinal Membrane:

Hypertensive Retinopathy:

Melbomian Gland Dysfunction (MGD):

Cataracts:

Retinal Detachment:

Lattice Degeneration:

Iritis / Uveitis / Iridocyclitis:

Stye / Hordeolum:

Glaucoma:

Macular Degeneration:

Posterior Vitreous Detachment (PVD):

Preseptal / Orbital Cellulitis:

Dry Eye Disease:

Have You Experienced Any Of The Following Symptoms In The Last 30 Days?

Blurred Vision At Distance:

Itchy Eyes:

Tired Eyes (Eye Fatigue):

Halos Around Lights:

Double Vision:

Dry, Gritty, Or Burning Sensation:

Glare At Nighttime:

Do You Have History Of Any Of The Following Eye Treatments Or Therapies?

Vision Therapy:

Ortho-K / CRT Contacts:

Myopia Management:

Blue Light Blocking Lenses:

Punctal Plugs / Punctal Occlusion:

Zeaxanthin / Lutein Supplementation:

LipiFlow:

Fish Oil / OMEGA-3 Supplementation:

Have You Had Any Of The Following Eye Surgeries Performed?

Cataract Surgery:

Corneal Transplant:

Trabeculoplasty:

LASIK:

Corneal Cross-Linking (CXL):

Glaucoma Laser Procedure (SLT/ALT):

PRK:

Retinal Laser:

Iris Laser:

RK:

Avastin / Lucentis Injections:

Blepharoplasty:

Eye Disease Not Listed:

Eye Surgeries Not Listed:

Eye Injuries:

Other Notes On Visual History:

MEDICAL HISTORY

PERSONAL MEDICAL HISTORY

Last Health Exam:

Medication Allergies:

No Known Drug Allergies

Current Medications Drops (Prescription or Over The Counter):	Taken For (Reason/Disease/Condition):

No Current Medications

REVIEW OF SYSTEMS

Height (ft):

inch:

Weight (lb):

Tetanus Shot Current?

Yes

Pregnant Or Nursing?

Yes

Due Date:

Kids - Birth/Dvpmt Hx:

General:

Ears, Nose, Throat:

Yes

Cardiovascular:

Yes

HTN?

Respiratory:

Yes

Genital, Kidney, Bladder:

Yes

Muscles, Bones, Joints:

Yes

Gastrointestinal:

Yes

Skin:

Yes

Neurological:

Yes

Psychiatric:

Yes

Endocrine:

Yes

Diabetes?

Type

Last A1C?

Blood/Lymph:

Yes

High Cholesterol?

Allergic/Immunologic:

Yes

Other Condition(s):

Yes

FAMILY MEDICAL HISTORY

Please Select "Other" To Type Multiple Answers Or Your Own Text.

Adopted: Family History Unknown

Blindness:

Cataracts:

Diabetes:

Eye Turn (Strabismus):

Lazy Eye (Amblyopia):

Glaucoma:

High Blood Pressure:

Macular Degeneration:

Other Disease:

SOCIAL HISTORY

Smoking Status

Discussed Cessation?

Do You Drink Alcohol?

EYE COMFORT QUESTIONNAIRE

1. during a typical day in the past month, how often did your eyes feel discomfort?

0 Never

1 Rarely

2 Sometimes

3 Frequently

4 Constantly

2. When your eyes felt discomfort, how intense was this feeling of discomfort at the end of the day, within two hours of going to bed?

0 Never Have It

1 Not At All Intense

5 Very Intense

3. During a typical day in the past month, how often did your eyes feel dry?

0 Never

1 Rarely

2 Sometimes

3 Frequently

4 Constantly

4. When your eyes felt dry, how intense was this feeling of dryness at the end of the day, within two hours of going to bed?

0 Never Have It

1 Not At All Intense

5 Very Intense

5. During a typical day in the past month, how often did your eyes look or feel excessively watery?

0 Never

1 Rarely

2 Sometimes

3 Frequently

4 Constantly

Policies, Consent, Submit Data

Authorized Users

Name:

Phone Number:

Address:

Email Address:

Please take time to read the following forms! Your signature here is equivalent to physically signing our office forms.

Preventative Eye Health Screenings

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Patient Signature

Date

Notice Of Privacy Practices

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Patient Signature

Date

Financial Policy

View Financial Policy

Patient Signature

Date