Online Patient Form

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After completing all the forms, please submit your data on the final tab. Thank you!

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
Primary Care Doctor
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

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:

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:

Medical History


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

Ocular History
Reason for Visit:

Last Eye Exam: Doctor:
Ocular Injuries/Surgeries:
Other Ocular History:
Any prescription or Over the Counter Drops?:

                                                                    Yes  No
Do you sometimes experience dry eyes?:   
Are you sensitive to sunlight?:   
Do you have problems with glare?:   
Do you like to spend time outdoors?:   
Review of Systems
General:
Ear, Nose, Throat:
Cardiovascular:
Respiratory:
Genitourinary:
Gastrointestinal:
Endocrine:
Musculoskeletal:
Skin:
Neurological:
Psychological:
Blood/Lymph:
Allergic/Immune:
Lifestyle
Living Situation: Hobbies:
Hours at Computer:

Smoking Status: Alcohol:

Height: ft. in.     Weight: lbs

Ethnicity: Race:
Preferred Language:
Medical History
Primary Care Physician:
Pregnant/Nursing: Last Physical Exam:

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

Medications: No current medications
Allergies: No known drug allergies
Vitamins/Supplements:

Major Injuries/Surgeries:
Other Medical History:
Family Medical History
Unknown family history
                                          You   Mother  Father  Sibling  None
High Blood Pressure:                                   
Thyroid:                                   
Cardiovascular Disease:                                   
Cancer:                                   
Diabetes:                                   
       Year Diagnosed:
               A1c:

                                          You   Mother  Father  Sibling  None
Glaucoma:                                     
Macular Degeneration:                                     
Retinal Detachment:                                     
Cataracts:                                     
Crossed/Lazy Eye:                                     

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