Online Patient Form

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Demographics


Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer / School Name
Primary Doctor Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Primary Vision

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary Vision

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Primary Medical

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary Medical

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

DMERC

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Chief Complaints


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Chief Complaints
Reason for Visit:
Secondary Complaints:

Ocular History
Patient Ocular History: Eye Medications:

Last Eye Exam: Doctor:

Primary Vision Correction: Do you have back up glasses? Planning to get new glasses?
Type of contacts worn in past: Wear Time: Cleaner:
Disposal:

Family Ocular History
Glaucoma: Cataracts: Macular Degeneration:
Retinal Detachment: Crossed or Lazy Eye:
Meaningful Use Demographic Information
Race: Ethnicity: Preferred Language:


Medical History


Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Patient Medical History
Past and/or Current Problems:

Injuries, Surgeries, Hospitalization:

Are You Pregnant Or Nursing: Recent Tetanus Shot:

Primary Care Physician: Last Visit: Reason For Visit:


Over The Counter Medications:
Vitamins:


Family Medical History

Social History
Occupation: Hobbies:

Smoking Status: Type: How Long:
Alcohol: Type: How Long:
Illegal Drugs: Type: How Long:
STD:


Review of Systems


Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!
General: (Ex. Fever, weight loss, weight gain, fatigue)
Ear/Nose/Throat: (Ex. Allergies, Sinus, Cough, Dry Mouth / Throat)
Cardiovascular: (Ex. High BP, Heart Surgery, Vascular Disease)
Respiratory: (Ex. Asthma, Bronchitis, Emphysema, COPD)
Genital/Kidney/Bladder: (Ex. Kidney Stones, Frequent Urination, impotence)
Muscles/Bones/Joints: (Ex. Arthritis, Joint Pains, Head or Neck Injury)
Skin: (Ex. Growths, Rashes, Acne)
Neurological: (Ex. Headaches, migraines, seizures)
Psychiatric: (Ex. Depression, Anxiety, Insomnia)
Endocrine: (Ex. Thyroid, Diabetes)
Blood/Lymph: (Ex. Anemia, cholesterol, bleeding problems)
Allergy/Immune: (Ex. Seasonal Allergies, AIDS, Lupus)
Gastrointestinal: (Ex. Diarrhea, Constipation, Ulcer, Reflux)



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