Online Patient Form

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Patient Information


TitleFirstLastMISuffixNickname
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Date Of Birth Occupation
Sex Employment Status
Marital Status Employer / School Name
Misc/Guardian

Billing Information

Is The Billing Address The Same?
TitleFirstLastMISuffix
Address:
City: State: Zip Code:
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:
Sex:
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:
Sex:
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:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary 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:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:




Preferred Language Race
Ethnicity Height Weight




Date Of Last Eye Exam Doctor's Name


Are You Interested In Contact Lenses? Yes No
Have You Ever Worn Contact Lenses? Yes No


Contact Lens Wearers: Are Your Lenses Comfortable? Yes No Current Brand


What Solution Do You Use? What Is Your Replacement Schedule? How Old Is Your Current Pair?


Are You Interested In Laser Vision Correction?



Social History



This Information Is Required By Insurance Carriers And Is Kept Strictly Confidential. However, You May Discuss This Portion Directly With The Doctor If You Prefer. I would like to discuss this with my doctor:

Question Yes No If Yes, Type/Amount/How Often
Do You Use tobacco Products?
Do You Drink Alcohol?
Do You Use Illegal Drugs?


Condition Yes No
Tuberculosis
Hepatitis
HIV
Syphillis
Chlamydia




Ocular History



Do You Have Any History Of The Following?

Condition Yes No
Blindness
Eye Turn (Strabismus)
Lazy Eye (Ambylopia)
Patching
Glaucoma
Cataracts
Macular Degeneration
Retinal Detachment
Eye Surgery
Eye Injury
Do You Experience Any Of The Following?

Condition Yes No
Blurred Vision
Burning
Eyes Feel Dry
Double Vision
Eyes Tear
Eyes "Hurt" Or "Tired"
Flashes
Floaters
Foreign Body Sensation
Eyes Itch
Bothered By Light/Sun Light
Halos Aroung Lights
Redness
Eyes Feel Sandy/Gritty
Mucous Discharge

Eye Meds:




Medical History / Review Of Systems



Primary Care Physician Last Visit


Do You Have Any Allergies To Medications? Yes No If Yes Please List:
Are You Pregnant Or Nursing? Yes No N/A


Do You Currently, Or Have You Ever Had, Any Problems In The Following Areas?

Constitutional
Fever Yes No
Weight Loss/Gain Yes No
Other

Integumentary (Skin)
Herpes Zoster (Shingles) Yes No
Eczema Yes No
Rosacea Yes No
Other

Neurological
Migraines Yes No
Seizures Yes No
Multiple Sclerosis Yes No
Other

Endocrine
Thyroid Problems Yes No
Diabetes Yes No
HbA1C Blood Sugar
Other

Allergic/Immunologic
Drug Allergy Yes No
Environmental Allergy Yes No
Lupus Yes No
Other

Respiratory
Asthma Yes No
Bronchitis Yes No
Emphysema Yes No
Other

Ear/Nose/Throat
Allergies/Hay Fever Yes No
Chronic Cough Yes No
Sinus Congestion Yes No
Other

Cardiovascular
Heart Disease Yes No
High Blood Pressure Yes No
Stroke Yes No
Vascular Disease Yes No
Other

Gastrointestinal
Crohn's Yes No
Colitis Yes No
Ulcer Yes No
Other

Genitourinary
Genital/Kidney/Bladder Yes No
Other

Musculoskeletal
Arthritis Yes No
Fibromyalgia Yes No
Muscular Dystrophy Yes No
Other

Hematologic/Lymphatic
Anemia Yes No
Leukemia Yes No
Bleeding Problems Yes No
Other

Psychiatric
Depression Yes No
Panic Disorder Yes No
Schizophrenia Yes No
Other


List Of Your Current Medication:


Please list any additional medical conditions that is not listed above.:


Family History - Family History Is Unknown / Adopted



Do Any of Your Immediate Family Members Have the Following (Parents, Grandparents, Siblings, Children)?

Condition Yes No Relationship To Patient Condition Yes No Relationship To Patient  
Lazy Eye (Ambylopia)   Retinal Detachment/Disease
Blindness   Macular Degeneration
Cataracts   High Blood Pressure
Glaucoma   Diabetes


ROS and PFS history reviewed today

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