Online Patient Forms

Patient information

First name

*This field is required

Last name

*This field is required

Nickname

Birth Sex

Male Female

Address

*This field is required

Apt/Suite #

City

*This field is required

State

*This field is required

Zip Code

*This field is required

Cell Phone

*This field is required

Home Phone

*This field is required

Preferred Contact Method

*This field is required

Birthday

*This field is required

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

*This field is required

Gender Identity

Marital Status

Misc/Guardian

Referral Information

Were you referred to our office?

*This field is required

If yes, whom may we thank?

Referral practice name

Would you like us to send the referring provider a summary of our findings and recommendations from today's examination?

Would you like a copy of todays examination emailed to you? (Please note that this may take up to 1 week after the evaluation)

Parent/Guardian Information (for child exams only)

Does the child live with both parents/guardian(s)?

If not, who does the child live with?

Primary Contact Information:

Guardian Name:

Relationship to patient:

Address:

Best Contact Phone Number:

Email:

Occupation/Employer:

Secondary Contact Information:

Guardian Name:

Relationship to patient:

Address:

Best Contact Phone Number:

Email:

Occupation/Employer:

Primary Medical Insurance

Insurance Information

Insurance Name:

Vision and Medical History

Reason for Visit:

Secondary Reasons:

Do you currently have any of these eye 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?

How often do you wear your glasses?

Contact Lens Wearers only

Type of contacts worn in the past:

Cleaner:

Disposal:

Wear Time:

Family Eye History

Macular Degen:

Glaucoma:

Retinal Detachment:

Cataracts:

Lazy / Crossed Eye:

Blindness:

Eye Turn (Strab)

Eye Tumor

Medications, Allergies, Other History

Medications No Medications

Over the Counter Medications

Vitamins

Drug allergies

Please Describe any Injuries or Surgeries you have had

Primary Care Physician

Last Visit

Reason

Pregnant or Nursing

Medical History

Do you have any of these medical conditions?

Diabetes

Hypertension

High Cholesterol

Thyroid Conditions

Heart Conditions

Cancer

Year Diabetes Diagnosed

Other (include Learning Differences/Disability):

Family Medical History

Unknown Family History

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

Hypertension

Diabetes

Thyroid

Cancer

High Cholesterol

Heart Conditions

Other (include Learning Differences/Disability):

Review Of Systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Social History

Hobbies

Smoking Status

Type

How long

Myopia/Nearsighted History (if applicable)

Do either birth parents have myopia?

Are there any siblings with myopia?

If your child wears glasses, at what age did they start wearing them?

Has the prescription increased in the last 6-12 months?

How many hours per day does your child spend outdoors (outside of school)?

How many hours per day does your child spend on a digital device (computer, phone, tablet)?

How many hours per day does your child spend reading?

If there was previous treatment for myopia, what method(s) were attempted and what were the results?

Communication Consent and HIPAA Privacy Notice

Please view the document by clicking the blue link, review and sign in the designated arew below on this tab, Thank you!

View Privacy Receipt, Communication Consent and HIPAA Privacy Notice Form

Yes, I give permission to San Diego Optometric Vision Therapy to communicate with me using the following methods: [CLICK ALL THAT APPLY: Email, phone, text, alternative phone numbers listed (i.e. home/work)]

Phone Call

Alternative Phone Number

Text

Signature

Date

Receipt of Notices of Privacy Practices

Signature

Date

Patient information

Referral Information

Parent/Guardian Information (for child exams only)

Primary Contact Information:

Secondary Contact Information:

Primary Medical Insurance

Vision and Medical History

Contact Lens Wearers only

Family Eye History

Medications, Allergies, Other History

Medical History

Do you have any of these medical conditions?

Family Medical History

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

Review Of Systems

Social History

Myopia/Nearsighted History (if applicable)

Vision Therapy History

(REQUIRED FOR VISUAL SKILLS EVALUATIONS)
Please fill out completely to the best of your ability.

Reading and Computer Symptom Checklist:

Child History:

Medical History

Developmental History:

Skills/ Milestones:

Strabismus / Amblyopia (If applicable):

Dizziness And Motion Sensitivity Checklist (If applicable):

TBI History (If applicable):

Brain Injury Vision Symptom Survey

Dry Eye History (If applicable)

Communication Consent and HIPAA Privacy Notice

Patient information

Referral Information

Parent/Guardian Information (for child exams only)

Primary Contact Information:

Secondary Contact Information:

Primary Medical Insurance

Vision and Medical History

Contact Lens Wearers only

Family Eye History

Medications, Allergies, Other History

Medical History

Do you have any of these medical conditions?

Family Medical History

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

Review Of Systems

Social History

Myopia/Nearsighted History (if applicable)

Vision Therapy History

(REQUIRED FOR VISUAL SKILLS EVALUATIONS) Please fill out completely to the best of your ability.

Reading and Computer Symptom Checklist:

Child History:

Medical History

Developmental History:

Skills/ Milestones:

Strabismus / Amblyopia (If applicable):

Dizziness And Motion Sensitivity Checklist (If applicable):

TBI History (If applicable):

Brain Injury Vision Symptom Survey

Dry Eye History (If applicable)

Communication Consent and HIPAA Privacy Notice

(REQUIRED FOR VISUAL SKILLS EVALUATIONS)
Please fill out completely to the best of your ability.