Online Patient Form

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Patient Information and Medical History Form

Thank you for using our secure online form. Please fill out as much information as you can.
When you are finished be sure to hit the submit button at the bottom of the form. If you have
any questions, please call us at 702-634-2020 (Seven Hills) or 702-871-3937 (the District).
We can always change the data in the office if you are unsure about what to enter in any of the field.

Title	First	Last	MI	Suffix	Nickname

Address:

City:	State:	Zip Code:

Home Phone:		Work Phone:
Cell Phone:		Preferred Contact Method:
SSN		Email
Birthday		Occupation/Grade:
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status		Employer / School Name
Misc/Guardian

Who may we thank for referring you to our office?:

Billing Information

Is The Billing Address the Same? Yes

Title	First	Last	MI	Suffix

Address:

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

Insurance Information

Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Are you the primary insurance holder?: Yes No

Primary on Account (Please fill out if you answered 'No' above)

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

Eye History

Do you have a history of any of these eye conditions?

	Yes	No
Glaucoma
Macular Degeneration
Retinal Conditions
Cataracts
Blindness
Crossed Eyes
Lazy Eye
Color Blindness
Double Vision
Serious Eye Infection
Flashes/Floaters

Other Eye Conditions? If so, please describe:

Have you had any eye surgeries? If so, please describe:

Have you had any eye injuries? If so, please describe:

Who was your previous eye doctor?:
When was your last eye exam?:

How many hours/day do you typically spend using a computer or other digital devices?:
How many hours/day do you spend driving?:
How many hours/day do you spend reading books, magazines, etc.?:

Do you have sunglasses?:
Do you have back-up glasses?:
Are you interested in contacts?:

Contact Lens Wearers Only

What disinfecting solution do you use?:
How many hours/day do you wear contacts?:
How many days/week do you wear contacts?:
How often do you replace your contacts?:
How old is your current pair of contacts?:

Medical History

Do you have a history of any of these conditions?

	Yes	No	Describe
Diabetes				A1c:
High BP
High Cholesterol
Thyroid Conditions
Heart Conditions
Cancer
Arthritis
Asthma
Migraines

Other Medical Conditions? If so, please describe:

Do you take any medications? If so, please list:

Are you allergic to any medications? If so, please describe:

Primary Care Physician:

Are you Pregnant or Nursing?:

Family Eye History

Does your family have a history of any of these eye conditions? Family History Unknown

	Mom	Dad	Sibling	Paternal Grandma	Paternal Grandpa	Maternal Grandma	Maternal Grandpa	None
Glaucoma
Macular Degeneration
Retinal Conditions
Cataracts
Lazy/Cross Eye
Blindness

Other Family Eye Conditions? If so, please describe:

Family Medical History

Does your family have a history of any of these conditions?

	Mom	Dad	Sibling	Paternal Grandma	Paternal Grandpa	Maternal Grandma	Maternal Grandpa	None
Diabetes
High BP
Thyroid Conditions
Heart Conditions
Cancer

Other Family Medical Conditions? If so, please describe:

Review of Systems

Allergy/Immune:
Musculoskeletal:
Cardiovascular:
Current:
Ears, Nose, Throat:
Endocrine:
Gastrointestinal:
Genitourinary:
Skin:
Blood/Lymph:
Neurological:
Psychiatric:
Respiratory:
Cancer:

Social History

Race:

Ethnicity:

Preferred Language:

Smoking Status:

Alcohol Use:

What are your hobbies/sports activities?:

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
Soreness or Irritation
Burning or Watering
Eye Fatigue

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