Online Patient Forms

Patient information

First name

*This field is required

Last name

*This field is required

Nickname

Birth Sex

Male Female

Address

Apt/Suite #

City

State

Zip Code

Cell Phone

*This field is required

Home Phone

Preferred Contact Method

Birthday

SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Pronoun

Gender Identity

Marital Status

Misc/Guardian

Authorized persons to release medical information to:

Billing information

How do you prefer to receive billing statements?

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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:

General Eye History

Last Eye Exam

Name of Doctor

Chief Complaint:

Secondary Complaint:

Do you or your family have any of the following?

Glaucoma:

Patient

Mother

Father

Sibling

No Describe:

Macular Degeneration:

Patient

Mother

Father

Sibling

No Describe:

Retinal Detachment / Disease:

Patient

Mother

Father

Sibling

No Describe:

Cataracts:

Patient

Mother

Father

Sibling

No Describe:

Amblyopia / Strabismus:

Patient

Mother

Father

Sibling

No Describe:

Ocular Injury / Surgery / Lazer:

Other Ocular History:

Do your eyes feel dry? Yes No

Are you bothered by fluctuating vision? Yes No

Do you currently use artifical tears? Yes No

If so what kind?

General Medical History

Primary Care Physician

Diabetes

Patient

Mother

Father

Sibling

No Describe:

Hypertension

Patient

Mother

Father

Sibling

No Describe:

Thyroid

Patient

Mother

Father

Sibling

No Describe:

Cardiovascular

Patient

Mother

Father

Sibling

No Describe:

Cancer

Patient

Mother

Father

Sibling

No Describe:

If YOU are diabetic, when were you diagnosed?

Last A1C level?

Are you Pregnant or Nursing?

Last Physical Exam?

List ALL major injuries or surgeries you have had and approx dates:

List any other medical conditions you have had, including non-drug allergies:

List all Rx and over-the-counter medications you currently take:

List any vitamins or supplements you currently take:

List any drug allergies you have:

Review Of Systems

Please list any problems you are currently having anywhere, from head to toe:

General (e.g., fever, fatigue, loss of appetite, unexplained weight loss/gain)

Ear, Nose, Throat (e.g., sinus/nasal congestion, nose bleeds, dry mouth/throat, sleep apnea, hearing problems)

Cardiovascular (e.g., chest pain, racing heartbeat, swollen feet/ankles, TIAs)

Pulmo

Genital, Kidney, Bladder (e.g., bladder/urinary problems, pain, discharge, menstrual changes, impotence)

Gastrointestinal (e.g., constipation, diarrhea, gastric reflux (GERD), jaundice, nausea, vomiting)

Endocrine (e.g., heat or cold intolerance, thinning hair, excess thirst, excess urination)

Muscles, Bones, Joints (e.g., pain, stiffness, swelling, weakness, limited movements)

Skin (e.g., dry, itchy, flaky, rash, growths, bumps, redness, discoloration)

Neurological (e.g., headaches, numbness/tingling, tremors, poor balance, dementia, speech problems)

Psychiatric (e.g., depression, anxiety, sleep problems, paranoia, obsessive/compulsive)

Blood/Lymph (e.g., anemia, bleeding gums, delayed clotting, unexplained bruising)

Allergy/Immune (e.g., swollen lymph nodes, itching, sneezing, runny nose/eyes)

Smoking Status

Alcohol Use

Race

Ethnicity

Preferred Language

Office Policies
Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below.

View All Office Policies

Patient's Name:* Patient's Date Of Birth:*

Patient / Guardian Signature:* Date:*

Patient's Name:*		Patient's Date Of Birth:*
Patient / Guardian Signature:*		Date:*