Online Patient Forms

Patient information

First name

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Last name

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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

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:

Primary Vision Insurance

Insurance Information

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account: Not Primary

Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Birth Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Primary Medical Insurance

Insurance Information

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account: Not Primary

Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

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

Chief Complaint

Detailed Reason for Todays Visit

Secondary Complaints

Review of Ocular System

Ocular History (e.g Glaucoma, Surgeries, Injuries)

Eye Drops (Over the counter tears or RX eye drops. e.g. Sustain, Refresh)

Last Eye Exam

Doctor

Primary Vision Correction

Do you:

Have Backup Glasses?

Want New Glasses?

Family Ocular History

Macular Degeneration

Glaucoma

Retinal Detachment

Cataracts

Lazy/Crossed Eye

While wearing your glasses, do you experience any of the following? (Please mark yes or no for each question)

Yes	No
		Blurred Vision Distance
		Blurred Vision Near
		Burning
		Crossed Eyes
		Distorted Vision (Halos)
		Double Vision
		Drooping Eyelid
		Dryness
		Excess Tearing/Watering
		Eye Pain/Soreness
		Flashes
		Floaters/Spots
		Fluctuating Vision
		Foreign Body Sensation

Yes	No
		Glare/Light Sensitivity
		Headaches
		Eye/Lid Infection
		Itching
		Lazy Eye (Eye Turn)
		Loss of Side Vision
		Loss of Vision
		Migraine
		Mucous Discharge
		Poor Color Vision
		Redness
		Sandy/Gritty Feeling
		Tired Eyes
		Twitching

Demographic Information

Race:

Ethnicity:

Preferred Language:

Review of Systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Cardiovascular

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Endocrine

Last Fasting Blood Sugar

HbA1C

Years with Diabetes

Patient Medical History

Primary Care Physcian

Last Visit

Reason For Visit

Injuries, Surgeries, Hospitalization

Pregnant Or Nursing

Recent Tetanus Shot

Medications No Medications

Drug allergies No Known Drug Allergies

Vitamins (OMEGA 3)

Over The Counter Meds

Pharmacy

Social History

Hobbies

Height

Weight

Smoking Status

Type

How long

Alcohol Use

Type

How long

Illegal Drug Use

Type

How long

STD

Dry Eye Speed Questionnaire

Dry Eye Disease

Environmental Factors
Systemic Conditions
Systemic Meds
Ocular Meds
Artificial Tears	Times/day
Signs
Contact Lenses

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	Symptoms at This Visit	Symptoms Within Past 72 Hours	Symptoms Within Past 3 Months
Dryness, Grittiness, Scratchiness	Yes No	Yes No	Yes No
Soreness or Irritation	Yes No	Yes No	Yes No
Burning or Watering	Yes No	Yes No	Yes No
Eye Fatigue	Yes No	Yes No	Yes No
Fluctuating Vision	Yes No	Yes No	Yes No

The Insured must please read and sign contract below

In order to control the cost of billing, we ask that the patients portion Is paid at the time services are rendered unless other arrangements are made in advance. We would rather control billing costs than be forced to raise our fees. All professional services and materials are charged to the patient. The undersigned will ultimately be responsible for any bill incurred in this office regardless of insurance. Accounts past due are subject to collection. I agree to pay any legal and collection agency fees and interest in the event of delinquency. There will be a service charge on all returned checks. Payment from my insurance is to be paid directly to Academy Vision. I understand that if my insurance denies payment, I will be responsible for the amount billed. I understand that billing any secondary insurance is my responsibility. I understand that all benefits quoted to me are not a guarantee of payment by my insurance company and that final determination can only be made when the claim is processed.

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