Online Patient Form

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Demographics


Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name
Misc/Guardian

How did you hear about our office?



Vision

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

Medical

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

Medical History

Eye History

Reason for Visit:

Secondary Reasons:

Primary Vision Correction: Planning to get new glasses?
Last Eye Exam: By Doctor:

Last Eye Doctor:

Have you ever worn soft contacts?:
Have you ever worn hard contacts?:

Do you use eye drops on a regular basis? If so, what and how often?

Have you ever had:
Eye Injuries (Foreign Objects, Black Eye, etc.)
Eye Disease (Cataract, Glaucoma, Pterygium, etc.)
Eye Surgery (Cataract, Vision Correction, etc.)

If yes to any of the above, please explain what and when:

Contact Lens Wearers Only

Type of CLs worn in past:

Wear Time:
Disposal:
Contact Solution:
Do you have back up glasses?:

Medical History

Medications:
Drug Allergies:

Primary Care Physician: Last Visit:
Preferred Pharmacy: City:

Pregnant Or Nursing:

Health History

Do you currently, or have you ever had any problems in the following areas?:

Ocular SymptomsYesNo
Eye Pain/Soreness
Fatigue/Tired Eyes
Dryness/Gritty Feeling
Redness
Burning
Itching
Excess Watering
Mucous Discharge
 
Visual Symptoms
Squinting
Glare
Light Sensitivity
Halos
Double Vision
Loss of Vision
Blurred Vision
Flashes
Floaters
GeneralYesNo
Weight Loss
Weight Gain
 
Skin
Rosacea
Metal Allergies
 
Ear/Nose/Throat
Allergies/Hay Fever
Hearing Loss
 
Respiratory
Asthma
Emphysema
 
Cardiovascular
Heart Problems/Disease
Congestive Heart Failure
High Blood Pressure
High Cholesterol
Stroke
GastrointestinalYesNo
Irritable Bowel Syndrome
Crohn's Disease
Colon Cancer
 
Endocrine
Thyroid/Graves
Diabetes Type I
Diabetes Type II
 
Blood/Lymph
Anemia
 
Autoimmune
Rheumatoid Arthritis
Lupus
Ankylosing Spondylitis
Sjogren's Syndrome
 
Neurological
Headaches
Migraines
Epilepsy/Seizures
Parkinson's
Injuries, Surgeries, Hospitalizations:

Family History

Do you have any family history (patents, siblings, grandparents) for the following?:

 YesNoRelationship to You
Ambylopia
Strabismus
Cataract
Glaucoma
Macular Degeneration
Cancer
Diabetes
Heart Disease
High Blood Pressure
Stroke
Thyroid Disease
Retinitis Pigmentosa

Social History

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

STD's?:

Race: Ethnicity: Language:

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