Online Patient Form

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Demographics


Title First Last MI Suffix Nickname
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?
Title First Last MI Suffix
Address

City State ZipCode
Home Phone:
Work Phone:

Primary Insurance Information

Insurance Name:
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 Information

Insurance Name:
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 Information

Insurance Name:
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:   Other Reasons:
  

Last Worn Contact Lenses: Interested in contacts?:

Last Exam: Which Office?: By Doctor:


Glasses History

I don't have a prescription
I lost my glasses
I broke my glasses
I didn't bring my glasses


Your Eye History                                                                                                                    Your Medical History

Glaucoma: Yes No                                                                                                  Diabetes: Yes No    Year Diagnosed: A1c:
Macular Degen: Yes No High BP: Yes No
Retinal Disease: Yes No High Cholesterol: Yes No
Cataracts: Yes No Heart Disease: Yes No
Lazy Eye: Yes No Thyroid: Yes No
Vision Loss: Yes No Cancer: Yes No
Crossed Eyes: Yes No Arthritis: Yes No
Dry Eyes: Yes No Asthma: Yes No
Color Blindness: Yes No Migraines: Yes No
Double Vision: Yes No
Eye Infections: Yes No
Flashes/Floaters: Yes No

Other Eye Conditions:                                                                                        Other Medical Conditions:
                                                                                      
Eye Surgeries:                                                                                        Medications:
                                                                                      
Eye Injuries:                                                                                        Drug Allergies:
                                                                                      

Primary Care Physician:


Family History Unknown

Family Eye History
   None    Mom    Dad    Sibling     Paternal
   Grandma		     Paternal
    Grandpa		    Maternal
   Grandma		    Maternal
   Grandpa
Glaucoma:                                                     
Macular Degen:                                                     
Retinal Detach:                                                     
Cataracts:                                                     
Lazy/Crossed Eye:                                                     
Blindness:                                                     

Other Family Eye Conditions:


Family Medical History
   None    Mom    Dad    Sibling     Paternal
   Grandma		     Paternal
    Grandpa		    Maternal
   Grandma		    Maternal
   Grandpa
Diabetes:                                                       
High BP:                                                       
Thyroid Disease:                                                       
Heart Disease:                                                       
Cancer:                                                       

Other Family Medical Conditions:


Review of Systems

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


Social History

Race:       
Hobbies: Computer Use:

Smoking Status: Alcohol Use: Illegal Drug Use:


Dry Eye Disease

Enviornmental Factors
Systemic Conditions
Systemic Meds
Ocular Meds
Artificial Tears Times/day
Signs
Contact Lenses

Frequency Legend: (rate on a scale of 3: 0 = Never, 1 = Tolerable, 2 = Often, 3 = Consistant)
Severity Legend: (rate on a scale of 4: 0 = No Problems, 1 = Tolerable, 2 = Uncomfortable, 3 = Bothersome, 4 = Intolerable)

Symptoms
Frequency
of Symptoms
Severity
of Symptoms
Symptoms
at This Visit
Symptoms
Within Past
72 Hours
Symptoms
Within Past
3 Months
Dryness, Grittiness, Scratchiness
Yes No
Yes No
Yes No
Soreness or Irritation
Yes No
Yes No
Yes No
Burning or Watering
Yes No
Yes No
Yes No
Eye Fatigue
Yes No
Yes No
Yes No
Fluctuating Vision
Yes No
Yes No
Yes No

OSDI Legend: (rate on a scale of 4: 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Often, 4 = Always)
Experienced In
The Following?		 Limited In Performing
The Following?		 Uncomfortable
In The Following?
Sensitivity To Light? Reading? Windy Conditions?
Gritty Feeling? Driving At Night? Low Humidity?
Painful Or Sore? Computer Use? Air Conditioning?
Blurred Vision? Watching TV? Poor Vision?

Submit Data