Online Patient Form

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Patient Information


Title First Last MI Suffix Nickname
Address:
Unit #
City: State: Zip Code:
Home Phone: Work Phone:
Other Phone:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Employer / School Name How did you hear about us?

Guarantor Information/Primary Person on Insurance

Is The Billing Address The Same?
First Last MI Suffix
Address:
City: State: Zip Code:
Home Phone:
Work Phone:

Medical History

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

Eye History

Exam Type (Annual Exam, Eye Health Check, Follow Up, etc):
Primary Concerns:

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:
Have you had any eye surgeries? Please describe:
Last Eye Exam:

Primary Vision Correction:

Contact Lens Wearers only
Type of contacts worn in the past: Cleaner: Disposal:
Wear Time:

Medical History

Medications (Including Eye Drops): Over The Counter Medications:
Vitamins: Drug Allergies:
Please describe any injuries or surgeries you have had:

Primary Care Physician:
Pregnant Or Nursing:


Do you have any of these medical conditions?: -

Diabetes: Year Diagnosed:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:

Family Medical History



Does anyone in your family have any of these medical conditions?:

High Blood Pressure: Diabetes:
Thyroid Conditions: High Cholesterol:
Heart Conditions: Other:
Cancer:

Family Eye History

Does anyone in your family have any of these eye conditions?:

Macular Degen: Glaucoma:
Retinal Detach: Cataracts:
Lazy/Crossed Eye: Blindness:

Review of Systems

General: Ear/Nose/Throat:
Skin: Cardiovascular:
Respiratory: Musculoskeletal:
Psychiatric: Gastrointestinal:
Endocrine: Blood/Lymph:
Neurological: Genitourinary:
Immune:

Social History

Hobbies:

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

Race: Ethnicity: Preferred Language:

Speed Questionnaire



Symptoms
Frequency
of Symptoms
(Frequency Legend Below)
Severity
of Symptoms
(Severity Legend Below)
Symptoms
at This Visit
Symptoms
Within Past
72 Hours
Symptoms
Within Past
3 Months
Dryness, Grittiness, Scratchiness
Yes No
Yes No
Yes No
Soreness or Irritation
Yes No
Yes No
Yes No
Burning or Watering
Yes No
Yes No
Yes No
Eye Fatigue
Yes No
Yes No
Yes No
Fluctuating Vision
Yes No
Yes No
Yes No

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)

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