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 Different? Yes

Title	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

Reason for Visit:

Primary Reasons:	Secondary Reasons:

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:

Last Appointment Type

By Doctor:

Primary Vision Correction:

Do you: Have back up glasses?

Want new glasses?

Contact Lens Wearers only

Type of contacts worn in the past:

Cleaner:

Disposal:

Wear Time:

Medical History

Medications: No Meds Used	Over The Counter Medications:

Vitamins:	Drug Allergies: No Known Drug Allergies

Please describe any injuries or surgeries you have had:

Primary Care Physician:

Last Visit:

Reason:

Pregnant Or Nursing:

Do you have any of these medical conditions?:

Diabetes:

Year Diagnosed:

Condition	None	Yes
Hypertension
Headaches / Migraines
High Cholesterol
Depression
Cardiovascular
Anxiety
Thyroid
Multiple Sclerosis
Autoimmune		Describe:
Cancer		Describe:

Other:

Family Medical History

Unknown family 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:
Keratoconus

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:
Illegal Drug Use:

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