Online Patient Form

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Patient Information


TitleFirstLastMISuffixNickname
Address:
City: State: Zip Code:
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:
City: State: Zip Code:
Home Phone:
Work Phone:

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

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:

Tertiary

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:

Fourth

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:

Medical History

Chief Complaint

Reason for Visit:
Location: Severity: Quality: Duration:
Timing: Context: Modifying: Associated:

Secondary Reasons:
Location: Severity: Quality: Duration:
Timing: Context: Modifying: Associated:



Review of Ocular System

Ocular History: Eye Meds:
Last Eye Exam: By Doctor:

Primary Vision Correction:
Back up glasses?: Want new glasses?:


Contact Lens History:

Type of contacts worn in past:
Cleaner: Disposal: Wear Time:
Day(s)/week hour(s) comfortably



Family Ocular History Unknown family history

Macular Degen: Glaucoma:
Retinal Detach: Cataracts:
Crossed / Lazy:



Review of Systems

General:       Ear/Nose/Throat:
Respiratory:       Genitourinary:
Skin:       Musculoskeletal:
Psychiatric:       Gastrointestinal:
Endocrine:       Cardiovascular:
Neurological:       Blood/Lymph:
Immune:



Medical History

Over The Counter Medications:    Vitamins:
   

Primary Care Physician: Last Visit: Reason:
Pregnant Or Nursing: Recent Tetanus Shot: Injuries, Surgeries, Hospitalization:



Family Medical History

Do you or your family have any of the following medical conditions?

Diabetes: Type: Year Diagnosed: HbA1C:

Blood Pressure: Describe:
High Cholesterol: Describe:
Thyroid Issues: Describe:
Cardiovascular: Describe:
Cancer: Describe:



Social History

Hobbies: STD's:

Smoking Status: Type: How Long:
Alcohol Use: Type: How Long:
Illegal Drug Use: Type: How Long:

Race: Ethnicity: Preferred Language:

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