Online Patient Form

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Demographics


Patient Information
Title First Last MI Suffix Nickname
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/Guardian Drivers License #
How did you hear abour us?



Medical History


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

Patient Ocular History

Patient Ocular Conditions
Ocular History
Eye Medications

Family Ocular History

Glaucoma
Macular Degeneration
Retinal Detachment
Cataract
Amblyopia / Strabismus
Blindness
Other Family Ocular Conditions

Family Medical History

Diabetes
Hypertension
Thyroid
Heart Disease
Cancer
Other Family Medical Conditions - Family History Unknown

Patient Medical History

Endocrine:
YrDx A1c
Allergic/Immunologic:
Musculoskeletal:
Cardiovascular:
Constitutional(Current):
Ears, Nose, Throat:
Gastrointestinal:
Genitourinary:
Integumentary (Skin):
Lymphatic/Hematologic:
Neurological:
Psychiatric:
Respiratory:
Cancer:
Other:
Other Patient Medical Conditions

Medications - No current medications
Allergies - No known drug allergies

Primary Care Physician
Referring Physician
Ref Phy Phone
Other Physicians
Last Medical Dr Appt

Smoking Status
Alcohol Use
Illegal Drug

Psychiatric:
Neurological:
Race
Preferred Language
Ethnicity


COVID-19 SCREENING



Within The Last 14 Days Have You Experienced Any Of The Following Symptoms:

Condition Yes No
Fever
Cough
Shortness Of Breath Or Difficulty Breathing
Chills
Repeated Shaking With Chills
Muscle Pain
Sore Throat
New Loss Of Taste Or Smell
Have You Traveled In The Last 14 Days?
Have You Or A Member Of Your Household Had Close Contact
With Or Cared For Someone Diagnosed With COVID-19 In The Last 14 Days?
Have You Or A Member Of Your Household Had Close Contact With Or Cared
For Someone With A Presumptive Positive Case Of COVID-19 In The Last 14 Days?
Has Anyone In Your Household Been Asked Or Required To Quarantine Based On Contact
With A Person Who Has A Confirmed Or Presumptive Positive COVID-19 Test Result Or Diagnosis,
Or Have You Been Asked To Quarantine?


Submit Data