Example Online Patient Form
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Demographics
Patient Information
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Rev.
Fr.
Miss
Address:
City:
State/ZipCode
TX
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
UT
VT
VI
VA
WA
WV
WI
WY
Home Phone:
Work Phone:
Other Phone:
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
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
TX
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
UT
VT
VI
VA
WA
WV
WI
WY
Home Phone:
Work Phone:
Chief Complaints
Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!
Chief Complaint:
Reason for Visit:
Secondary Complaints:
Notes:
Past Surgeries
Date:
Type:
Notes:
Major Illnesses
Date:
Type:
Notes:
Demographics
Race:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other Race
Patient Declined to Specify
Other
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Other
Patient Declined to Specify
Other
Preferred Language:
English
French
German
Spanish
Other
Social History
Hobbies:
Smoking Status
Never smoker (<100 cigs equiv)
Former smoker (no longer smokes)
Current some day smoker (not daily)
Light smoker (<10 cigs/day)
Heavy smoker (>10 cigs/day)
Smoker (current status unknown)
Current every day smoker
Unknown if ever smoked
Other
Type:
None
Cigaretts
Chewing Tobacco
Other
How Long:
Alcohol:
No
Yes
Occasionally
Socially
Other
Type:
None
Beer
Wine
Hard Liquor
Other
How Long:
Illegal Drugs:
No
Yes
Other
Type:
N/A
Other
How Long:
Tobacco Cesssation Counseling?
N/A
Yes
No
Other
Past Smoker?
No
Yes
Other
Quit Smoking When?
N/A
Other
Do you use chewing tobacco?
No
Yes
Other
Marital Status:
Married
Single
Divorced
Widowed
Other
Engage in regular exercise?
Yes
No
Other
STD:
None
Gonorrhea
Syphilis
Hepatitis
HIV
TB
Other
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
General:
None
Fatigue
Fever
Loss of Appetite
Weight Gain
Weight Loss
Developmental Disorders
Other
Ear/Nose/Throat:
None
Neck Problems
Sinus Problems
Sore Throat (Recent)
Headache
Morning Headaches
Migraine Headache
Cluster Headache
Hearing Loss
Tinnitus
Congestion
Dry throat / mouth
Sleep Apnea
Other
Skin:
None
Acne
Lupus
Dermatitis
Eczema
Psoriasis
Rosacea
Skin Cancer
Itching
Other
Cardiovascular:
None
Congestive Heart Disease
Cardivascular Disease
High Cholesterol
Hypertension
Arrhythmia
Heart Murmur
Heart Palpitation
Chest Pain
Arteriosclerosis
Coagulation Disorder
Mitral Valve Prolapse
Low Blood Pressure
Other
Respiratory:
None
Asthma
Cancer: lung
Sleep Apnea
Sarcoidosis
COPD
Emphysema
Pneumonia
Bronchitis
Shortness of breath
Wheezing
Other
Musculoskeletal:
None
Arthritis
Osteoporosis
Fibromyalgia
Osteoarthritis
Muscular Dystrophy
Lupus
Decreased range of motion
Muscle cramps
Pain/tenderness
Stiffness
Swelling
Weakness
Other
Psychiatric:
None
Attention Deficit Disorder
Anxiety
Brain Damage (trauma)
Panic Attacks
Alzheimers Disease
Bi-polar
Depression
Insomnia
Obsessive/Compulsive
Paranoia
Suicidal
Violence
Other
Gastrointestinal:
None
Acid Reflux
Crohn's disease
Gastric reflux (GERD)
IBS
Ulcer
Gall bladder problems
Jaundice
Hepatitis
Sarcoidosis
Cancer: colon
Cancer: Liver
Other
Endocrine:
None
Crohn's disease
Diabetes Type 1
Diabetes Type 2
Diabetes Suspect
Hypothyroid
Hyperthoyroid
Gout
Hormone Replacement Therapy
Other
Blood/Lymph:
None
Anemia
Hx of Significant Blood Loss
Hematologic Disorder
Sickle Cell Disorder
Breast Carcinoma
Lymph Node Disease
Temporal Arthritis
Cuts slow to clot
Easy bruising
Other
Neurological:
None
Multiple Sclerosis
Seizure Disorder
Parkinsons Disease
Brian Tumor
Bells Palsy
Dyslexia
Headache
Balance problems
Vertigo
Tremors
Changes in senses
Dementia
Memory problems
Muscle weakness
Numbness, paralysis
Personality changes
Speech problems
Other
Genitourinary:
None
Amenorrhea
Menopause
Impotence
Jaundice
Uterine Cancer
Prostate Cancer
Kidney Stones
Pregnant
Nursing
Syphilis
Prostate Problems
Bladder Infections
STD- herpetic
STD- chlamydia
Other
Immune:
None
Seasonal allergies
Environmental allergies
Food allergies
Drug allergies (please specify)
Sjogrens syndrome
AIDS
Herpes Simplex
HIV Simplex
Mononucleosis
Tuberculosis
Cytomegalovirus Infection
Herpes Zoster
Lyme Disease
Sarcoidosis
Syphilis
Hives
Itching
Mild allergy symptoms
Severe allergy symptoms
Swelling
Other
Family Medical History
Eye Diseases:
Relationship to Patient:
Amblyopia:
No
Aunt
Brother
Cousin
Daughter
Grandfather
Grandmother
Father
Mother
Sister
Son
Uncle
Other
Blindness:
No
Aunt
Brother
Cousin
Daughter
Grandfather
Grandmother
Father
Mother
Sister
Son
Uncle
Other
Cataract:
No
Aunt
Brother
Cousin
Daughter
Grandfather
Grandmother
Father
Mother
Sister
Son
Uncle
Other
Color Defeciency:
No
Aunt
Brother
Cousin
Daughter
Grandfather
Grandmother
Father
Mother
Sister
Son
Uncle
Other
Eye Tumors:
No
Aunt
Brother
Cousin
Daughter
Grandfather
Grandmother
Father
Mother
Sister
Son
Uncle
Other
Glaucoma
No
Aunt
Brother
Cousin
Daughter
Grandfather
Grandmother
Father
Mother
Sister
Son
Uncle
Other
Macular Degeneration
No
Aunt
Brother
Cousin
Daughter
Grandfather
Grandmother
Father
Mother
Sister
Son
Uncle
Other
Retinal Detachment
No
Aunt
Brother
Cousin
Daughter
Grandfather
Grandmother
Father
Mother
Sister
Son
Uncle
Other
Strabismus
No
Aunt
Brother
Cousin
Daughter
Grandfather
Grandmother
Father
Mother
Sister
Son
Uncle
Other
Systematic Diseases:
Patient Notes:
Arthritis:
No
Aunt
Brother
Cousin
Daughter
Grandfather
Grandmother
Father
Mother
Sister
Son
Uncle
Other
Cancer:
No
Aunt
Brother
Cousin
Daughter
Grandfather
Grandmother
Father
Mother
Sister
Son
Uncle
Other
Diabetes:
No
Aunt
Brother
Cousin
Daughter
Grandfather
Grandmother
Father
Mother
Sister
Son
Uncle
Other
Heart Disease:
No
Aunt
Brother
Cousin
Daughter
Grandfather
Grandmother
Father
Mother
Sister
Son
Uncle
Other
High Blood Pressure:
No
Aunt
Brother
Cousin
Daughter
Grandfather
Grandmother
Father
Mother
Sister
Son
Uncle
Other
Kidney Disease:
No
Aunt
Brother
Cousin
Daughter
Grandfather
Grandmother
Father
Mother
Sister
Son
Uncle
Other
Lupus:
No
Aunt
Brother
Cousin
Daughter
Grandfather
Grandmother
Father
Mother
Sister
Son
Uncle
Other
Stroke:
No
Aunt
Brother
Cousin
Daughter
Grandfather
Grandmother
Father
Mother
Sister
Son
Uncle
Other
Thyroid Disease:
No
Aunt
Brother
Cousin
Daughter
Grandfather
Grandmother
Father
Mother
Sister
Son
Uncle
Other
Patient Medical History
Primary Care Physcian:
Last Visit:
1 week
1 month
3 months
6 months
1 year
2 years
Other
Reason For Visit:
Check up
Annual
Other
Height:
Ft.
In.
Weight:
Lbs.
Current Medications
Allergy History:
Vitamins:
None
A
E
C
Zinc
Xanten
Lutein
Other
Over The Counter Medications:
None
Asprin
Acetomenophin
Ibuprofen
Other
Pregnant Or Nursing:
No
Yes
Unsure
Other
Recent Tetanus Shot:
Yes
No
Other
Notes:
Diabetics
Blood Sugar:
Date Blood Sugar was Taken:
HbA1C:
Date HbA1C was Taken:
Visual History
Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!
Patient Eye Diseases
If yes, how long has this been a problem? Please briefly describe:
Amblyopia:
No
Yes
Other
Blepharitis:
No
Yes
Other
Blindness:
No
Yes
Other
Cataracts:
No
Yes
Other
Color Blindness:
No
Yes
Other
Eye Injuries:
No
Yes
Other
Diabetic Retinopathy:
No
Yes
Other
Glaucoma:
No
Yes
Other
Glaucoma Suspect:
No
Yes
Other
High Risk Medication:
No
Yes
Other
Macular Degeneration:
No
Yes
Other
PVD:
No
Yes
Other
Retinal Detachment:
No
Yes
Other
Strabismus:
No
Yes
Other
Other:
No
Yes
Other
Patient Current Eye Symptoms
If yes, please briefly describe:
Headaches:
No
Yes
Other
Light Sensitivity:
No
Yes
Other
Tired Eyes:
No
Yes
Other
Burning:
No
Yes
Other
Dryness:
No
Yes
Other
Epiphora:
No
Yes
Other
Eyelid Swelling:
No
Yes
Other
Eye Pain or Soreness:
No
Yes
Other
Foreign Body Sensation:
No
Yes
Other
Infection of Eyelid:
No
Yes
Other
Itching:
No
Yes
Other
Mucous:
No
Yes
Other
Ptosis (Drooping Eyelid):
No
Yes
Other
Redness:
No
Yes
Other
Sandy or Gritty Feeling:
No
Yes
Other
Blurred Vision Distance:
No
Yes
Other
Blurred Vision Near:
No
Yes
Other
Distorted Vision:
No
Yes
Other
Double Vision:
No
Yes
Other
Flashes of Lights:
No
Yes
Other
Floaters or Spots:
No
Yes
Other
Fluctuating Vision:
No
Yes
Other
Loss of Vision:
No
Yes
Other
Other:
No
Yes
Other
Additional Notes:
Review of Ocular System
Last Eye Exam:
1 year
2 years
3 years
Other
Doctor:
Dr. Bishop
Dr. Kautz
Other
Primary Vision Correction:
None
Glasses-Full Time
Glasses-Readers Only
Contacts - Soft
RGPs
PMMA
OTC readers
Other
Do you have backup glasses?
Yes
No
Other
Do you want new glasses?
Yes
No
Other
Type of CLs worn in past:
None
Disposable
Conventional
Colored
RGP
PMMA
Cobalt Study Lens
Soft
Other
Cleaner:
Optifree
Clear Care
Boston
Renu
Other
Disposal:
2 weeks
monthly
daily
weekly
yearly
Other
Wear Time:
>2 hours today
All day
Occ. Overnight
Extended
8 hours
10 hours
12 hours
Overnight
Other
Hours per Day:
Days per Week:
NOTES:
OSDI
Patient Ocular Information
Rate each of the following from 0-4, where 0=never, 1 = rarely, 2 = sometimes, 3 = often, 4 = always
Experienced the following?
Limited in performing the following?
Uncomfortable in the following?
Sensitivity to light?
0
1
2
3
4
Other
Reading?
0
1
2
3
4
Other
Windy conditions?
0
1
2
3
4
Other
Gritty feeling?
0
1
2
3
4
Other
Driving at night?
0
1
2
3
4
Other
Low humidty?
0
1
2
3
4
Other
Painful or sore?
0
1
2
3
4
Other
Computer use?
0
1
2
3
4
Other
Air conditioning?
0
1
2
3
4
Other
Blurred vision?
0
1
2
3
4
Other
Watching TV?
0
1
2
3
4
Other
Poor vision
0
1
2
3
4
Other
Submit Data
EYECARE CENTER OF SALEM
ACKNOWLEDGMENT AND CONSENT
I understand that The Eyecare Center of Salem (referred to below as "This Practice") will use and disclose health information about me.
I understand that my health information may include information both created and received by the practice, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information.
I understand and agree that This Practice may use and disclose my health information in order to:
make decisions about and plan for my care and treatment;
refer to, consult with, coordinate among, and manage along with other health care providers for my care and treatment;
determine my eligibility for health plan or insurance coverage, and submit bills, claims and other related information to insurance companies or others who may be responsible to pay for some or all of my health care; and
perform various office, administrative and business functions that support my physicianâââ‰â¢s efforts to provide me with, arrange and be reimbursed for quality, cost-effective health care.
I also understand that I have the right to receive and review a written description of how This Practice will handle health information about me. This written description is known as a Notice of Privacy Practices and describes the uses and disclosures of health information made and the information practices followed by the employees, staff and other office personnel of This Practice, and my rights regarding my health information.
I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy Practices. I also understand that a copy or a summary of the most current version of This Practice's Notice of Privacy Practices in effect will be posted in waiting/reception area and available on the website at eyecarecenterofsalem.com.
I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that This Practice is not required by law to agree to such requests.
By signing below, I agree that I have reviewed and understand the information above and that I have received a copy of the Notice of Privacy Practices.
Financial Notice (ABN)
The patient's portion of charges is due at the time of service. There will be a service charge on all returned checks. Unpaid accounts will be forwarded to our collection agency. Payment from my insurance is to be paid directly to Eyecare Center of Salem, LLC. 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.
By signing below, I agree that I have reviewed and understand the information above and that I have received a copy of the Notice of Privacy Practices. Please check, sign and date that you have read, understand, and agree to the above, then click the submit data button to complete your online forms. Thank you!
Check:
Patient Signature:
Date:
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