Online Patient Form

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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
Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Ins 1

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:

Ins 2

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:

Ins 3

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:

Ins 4

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:

Other

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

Medical History

Last Eye Exam:

Please list any medications you currently take:
Please list any medication you're allergic to:

Primary Care Doctor:
Doctors Address/Phone#/Fax:


Do you experience:

Blurred Vision: Headaches:
Eyestrain/Fatigue: Glare:
Double Vision: Floaters:
Watery Eyes: Dry Eyes:
Itchy Eyes: Redness:
Flashes of Light:

Have you or your family ever had any of the following:

 Yes/NoRelationship
Lazy Eye:
Blindness:
Cataracts:
Color Blindness:
Glaucoma:
Macular Degeneration:
Retinal Detachment:
Strabismus/Eye Turn:
Eye Surgery:
                                      List of Eye Surgeries:

Review of Systems

Do you currently have any of these health problems?

 Yes / NoDescribe:
General: (Ex. Fever, Weight Loss, Weight Gain, Fatigue)
Ear/Nose/Throat: (Ex. Allergies, Sinus, Cough, Dry Mouth / Throat)
Cardiovascular: (Ex. High BP, Heart Surgery, Vascular Disease)
Respiratory: (Ex. Asthma, Bronchitis, Emphysema, COPD)
Genitourinary: (Ex. Kidney Stones, Frequent Urination, Impotence)
Musculoskeletal: (Ex. Athritis, Joint Pains, Head or Neck Injury)
Skin: (Ex. Growths, Rashes, Acne)
Neurological: (Ex. Headaches, Migraines, Seizures)
Psychiatric: (Ex. Depression, Anxiety, Insomnia)
Endocrine: (Ex. Thyroid, Diabetes)
Blood/Lymph: (Ex. Anemia, Cholesterol, Bleeding Problems)
Allergy/Immune: (Ex. Seasonal Allergies, Rheumatoid, AIDS, Lupus)
Gastrointestinal: (Ex. Diarrhea, Constipation, Ulcer, Reflux)

Are you currently pregnant/nursing?:

Family Medical History

Has anyone in your family ever had any of the following:

Arthritis:
Cancer:
Diabetes:
Heart Disease:
High Blood Pressure:
Kidney Disease:
Autoimmune Disease:
Stroke:
Thyroid Disease:
Other:

Social History

Ethnicity: Race:

Do you drink alcohol?: Yes No     How much per day/week?
Do you smoke?: Yes No     How much per day/week?
Do you use illegal drugs?: Yes No

Lifestyle

Do you drive?: Yes No     Visual difficulty with driving?: Yes No
Do you use a computer?: Yes No     Hours per day:

Sports/Hobbies:

Do you wear sunglasses?: Yes No
Are you interested in wearing contact lenses?: Yes No
Do you want information on laser vision correction?: Yes No
Do you have any family members in need of eyecare?: Yes No

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