Online Patient Form

Medical History

Exam Type

Exam Emergency Visit Rx Check Dilation Pressure Check Other

Occupation

PCP

Grade

Age

Race	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander Other Race Patient Declined to Specify Unknown White

Ethnicity

Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify

REASON FOR VISIT, HPI

Do you have or have you ever been diagnosed with diabetes or pre-diabetes?

Yes

No

How long?

Fasting blood sugar

HbA1c Lab Test Result

When was it taken?

Diabetic medications

Hypertension

Yes No

High Cholesteral

Yes No

Heart problems

Stroke

Hyperthyroid

Hypothyroid

Autoimmune

Cancer

Medications

Allergies (drug)

Allergies (non-drug)

Last eye exam

Personal Medical History

OPHTHALMIC

Vision Loss

Blurry Vision

Distorted Vision

Dry Eyes

Redness

Discharge

Double Vision

Retinal Detachment

Gritty Feelings

Itching

Excess Watering

Light Sensitivity

Lazy Eye (eye turn or weak vision)

Burning

Eye Pain

DM Retinopathy

Glaucoma

Infection

Stye

Pterygium

Flashes

Floaters

Tired Eyes

Cataracts

Macular Degeneration

Refractive Surgery (LASIK or other)

Other

Family Medical History

Blindness	None Grandparent Parent Sibling Aunt/Uncle Child Unknown Other	Cataract	None Grandparent Parent Sibling Aunt/Uncle Child Unknown Other
Macular Degeneration	None Grandparent Parent Sibling Aunt/Uncle Child Unknown Other	Glaucoma	None Grandparent Parent Sibling Aunt/Uncle Child Unknown Other
Retinal Detachment	None Grandparent Parent Sibling Aunt/Uncle Child Unknown Other	Diabetes	None Grandparent Parent Sibling Aunt/Uncle Child Unknown Other
Diabetic Retinopathy	None Grandparent Parent Sibling Aunt/Uncle Child Unknown Other	High Blood Pressure	None Grandparent Parent Sibling Aunt/Uncle Child Unknown Other
Cross Eyed	None Grandparent Parent Sibling Aunt/Uncle Child Unknown Other	Cancer	None Grandparent Parent Sibling Aunt/Uncle Child Unknown Other

Social History

Drives	Drives Doesn't drive Other	Alcohol use	Not drinker Occasional drinker Every day drinker Other
Smoking Status	Unknown if ever smoked Never smoked Former smoker Light Smoker Heavy Smoker Other	Hrs CRT use	No CRT use Miminal CRT use Extensive CRT Use Other
Rec Drugs	No rec drugs Previous drug user Current drug user Other	Pregnant or Nursing	Not nursing/pregnant Nursing/pregnant Other
Hobbies:	None Listed Astronomy Art Baseball Boating Basketball Cooking Crafts Dancing Diving Football Fishing Golf Gardening Horseback Riding Hunting Models Needlepoint None Painting Photography Piano Reading Running Roller Blading Softball Sewing Skiing Soccer Swimming Tennis Video Games Woodworking Other