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 Employment Status
Marital Status Employer / School Name
Misc/GuardianDrivers License #



Chief Complaint

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Chief Complaint(s)


History of Chief Complaints


Systemic Medications Taken for:


Major Illness or Injuries


Ocular Medications Amt Eye Dosage


Diabetic Info

Last Blood Sugar: unknown
mg / dL


Last HbA1c: unknown
%


Level Of Control: Controlled Not Controlled

PCP following every:


Surgeries Surgery Dates Surgeon


Allergies

Drug Allergies Yes No

If yes, list the medications
Symptoms of Drug Allergies
Specific Allergies


Primary Care Physician Information

Last exam
PCP Name
Address
Phone
Fax




Ocular History

Preliminary History

Blurred Vision Dist. Yes No
Blurred Vision Near Yes No
Double Vision Yes No
Flashing Lights Yes No
Fluctuating Vision Yes No
Loss of Vision Yes No
Floaters or Spots Yes No
Burning Yes No
Dryness Yes No
Epiphora/Tearing Yes No
Eye Pain or Soreness Yes No
Foreign Body Sensation Yes No
Itching Yes No
Mucous Discharge Yes No
Ptosis (Drooping Eyelid) Yes No
Redness Yes No
Sandy or Gritty Feeling Yes No
Headaches Yes No


Eye History

Glaucoma Yes No
Cataract Yes No
Macular Degen Yes No
Cornea Yes No
Retina Yes No
Amblyopia (Lazy Eye) Yes No
Strabimus (Crossed Eyes) Yes No
Eye/Lid Infection (Bleph, Stye) Yes No
Other Yes No


Review Of Systems

Ear, Nose, Throat Yes No
Blood/Lymph (Cholesterol/Anemia) Yes No
Genital, Kidney, Bladder Yes No
Cardiovascular (Heart, BVs) Yes No
Respiratory (Asthma, COPD) Yes No
Gastrointestinal Yes No
Endocrine (DM1/DM2, Thyroid) Yes No
Neurological (MS, etc.) Yes No




Family And Social History

Eye Disease

Amblyopia (Lazy Eye)YesNo Relationship:
BlindnessYesNo Relationship:
Cataract(s)YesNo Relationship:
Color Blindness YesNo Relationship:
Glaucoma YesNo Relationship:
Macular Degeneration YesNo Relationship:
Retinal Detachment YesNo Relationship:
Strabismus (Eye Turn)Yes No Relationship:


Systemic Disease

Arthritis YesNo
Cancer YesNo
Diabetes YesNo
Heart Disease Yes No
High Blood Pressure YesNo
Kidney Disease YesNo
Lupus YesNo
Stroke YesNo
Thyroid Disease YesNo
Other YesNo


Demographics

Race
Ethnicity


Spectacle Use

Do You Currently Wear Glasses? Yes No Since FT PT Dist Near

Have You Had Trouble With Past Glasses? Yes No

Do You Wear Sunglasses? Yes No Current Prescription? Yes No

Occupation Years Employer

Do You Drive? Yes No Distance to Work?

Do You Have Difficulty: With DrivingYes No Glare? Yes No Night Vision? Yes No

Glasses Owned? Single Vision Trifocals Safety Glasses Progressive Bifocals Backup Sports Other:

Special Eye Wear Needs: Computer Lenses Occupational Safety Glasses Sports / Hobbies

Computer Used Yes No Distance Hours Per Day

Hobbies / Interests Alcohol Use?

Exercise Regularly? Yes No Nutritional Supplements Yes No

Smoking Status

Tobacco Intake Method:

Have You Ever Tried CLs? Yes No Current Wearer Yes No Since

Type: Hrs Per Day? Time Worn Today:

Cleaner
Disinfectant
Enzyme


Reason for Stopping: Interested In Trying CLs today?


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Notice of Privacy Practices

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Patient Signature: Date:

Financial Policy

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Patient Signature: Date: