Online Patient Form

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Patient Information

Title	First	Last	MI	Suffix	Nickname

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
Misc/Guardian

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:

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!

Reason for Visit:
Secondary Reasons:

Eye History

Ocular History:

Eye Meds:

Primary Vision Correction:

Back up glasses?:

Getting new glasses?:

Type of contacts worn in past:

Wear Time:

Cleaner:

Disposal:

Last Eye Exam:

By Doctor:

Medical History

Problems:

Injuries, Surgeries, Hospitalization:

Pregnant Or Nursing:

Primary Care Physician:

Last Visit:

Last Full Eye Exam:

Over The Counter Meds:

Vitamins:

Medications: No current meds

Drug Allergies: No Known Drug Allergies

Family Medical History

Please note and family history (parents, grandparents, siblings) for the following: Unknown family history

Condition	Yes	No	Relationship to You
Blindness
Crossed Eyes
Cataract(s)
Glaucoma
Macular Degeneration
Retinal Detachment

Condition	Yes	No	Relationship to You
Diabetes
Heart Disease
High Blood Pressure
Stroke
Thyroid Disease
Cancer

Review of Systems

Do you currently, or have you ever had any problems in the following areas:

Eyes (Ocular Symptoms)	Yes	No
Eye Pain/Soreness
Fatigue/Tired Eyes
Foreign Body Sensation
Dryness/Gritty Feeling
Redness
Burning
Itching
Excess Watering
Mucous Discharge
Chronic Eye Infection
Sties/Chalazion

Eyes (Visual Symptoms)
Squinting
Glare/Light Sensitivity
Distorted Vision/Halos
Double Vision
Loss of Vision
Loss of Side Vision
Blurred Vision
Flashes
Floaters

General	Yes	No
Fever
Weight Loss/Gain

Skin
Metal Allergies

Ears/Nose/Mouth/Throat
Allergies/Hay Fever
Sinus Infections
Hearing Loss
Rosacea

Respiratory
Asthma
Chronic Bronchitis
Emphysema

Cardiovascular
Heart Problems/Disease
Congestive Heart Failure
High Blood Pressure
High Cholesterol
Stroke

Genitourinary
Genitals/Kidney/Bladder

Gastrointestinal	Yes	No
Acid Reflux
Intestinal Problems
Liver Problems

Endocrine
Thyroid/Other Glands
Diabetes

Blood/Lymph
Anemia
Bleeding

Bones/Joints/Muscles
Rheumatoid Arthritis
Muscle/Joint Pain

Neurological
Headaches
Migraines
Seizures
Parkinson's
Alzheimer's

Psychiatric/Immune
Psychiatric Conditions
Immune Conditions

Social History

Hobbies:

Do you drive?:

If yes, do you have difficulty when driving?:

If yes, describe:

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

Race:

Ethnicity:

Preferred Language:

Height:	ft.	in.
Weight:	lbs.

Online Patient Form

Patient Information

Billing Information

Insurance Information

Medical History

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