Online Patient Forms
Patient information
First name
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MI
Last name
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Nickname
Birth Sex
Male
Female
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Address
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Apt/Suite #
City
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Zip Code
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State
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
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Cell Phone -
10 Digits (No Dashes)
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Home Phone
Email
Preferred Contact Method
Home Phone
Work Phone
Cell Phone
Other Phone
Text Message
Email
Birthday
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SSN
Occupation
Employment Status
Employed
Fulltime Student
Parttime Student
Employer/School Name
Pronoun
he/him/his
she/her/hers
they/them/theirs
Gender Identity
Additional gender category (or other)
Decline to answer
Female-to-Male (FTM)/Transgender Male/Trans Man.
Genderqueer, neither exclusively male nor female
Identifies as Female
Identifies as Male
Male-to-Female (MTF)/Transgender Female/Trans women
Marital Status
Annulled
Divorced
Domestic partner
Interlocutory
Legally Separated
Married
Never Married
Widowed
Would you like us to wear a mask during the visit?
Yes
No
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Medical History
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Eye History
Reason for Visit
Primary Reason
Secondary Reason
Do you currently have any of these eye symptoms?
Itching
Burning, Stinging
Red eyes
Floaters
Flashes Of Light
Eye Injuries
Eye Surgery
Amblyopia
Strabismus
Cataracts
Glaucoma
Retinal Disorders
Other
Do you currently take any of these medications?
None
Cromolyn NA 4%
Visine
Patanol
Xalatan
Travatan
rewetting drops
Elestat
Vigamox
Alphagan
Refresh
Theratears
Genteal
Pred Forte
Lotemax
Alrex
Systane
Blink
Other
Have you had any eye surgeries? Please describe
Last Eye Exam
1 year
2 years
3 years
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Last Appointment Type
By Doctor
Primary Vision Correction
None
Prescription Glasses
Prescription Reading Glasses
Soft Contacts
Non-Prescription Reading Glasses
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Do you:
Have Backup Glasses?
Yes
No
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Want New Glasses?
Yes
No
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Contact Lens Wearers only:
Type of Contacts worn in the past
Cleaner
Disposal
Wear Time
Medical 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
1 week
1 month
3 months
6 months
1 year
2 years
greater than 3 years
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Reason
Check up
Annual
Specific
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Pregnant or Nursing
Yes
No
Unsure
Do you have any of these medical conditions?
Diabetes
Yes
No
Unsure
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Hypertension
Yes
No
Unsure
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High Cholesterol
Yes
No
Unsure
Type in your own text
Thyroid Conditions
Yes
No
Unsure
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Heart Conditions
Yes
No
Unsure
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Cancer
Yes
No
Unsure
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Year Diabetes Diagnosed
Other
Family Medical History
Does anyone in your family have any of these medical conditions?
Unknown Family History
Hypertension
No
Parents
Siblings
Grandparent
Other
Diabetes
No
Parents
Siblings
Grandparent
Other
Thyroid
No
Parents
Siblings
Grandparent
Other
Cancer
No
Parents
Siblings
Grandparent
Other
High Cholesterol
No
Parents
Siblings
Grandparent
Other
Heart Conditions
No
Parents
Siblings
Grandparent
Other
Other
Family Eye History
Does anyone in your family have any of these eye conditions?
Macular Degen
No
Parents
Siblings
Grandparent
Other
Glaucoma
No
Parents
Sibling
Grandparent
Other
Retinal Detach
No
Parents
Siblings
Grandparent
Other
Blindness
No
Parents
Siblings
Grandparent
Other
Cataracts
No
Parents
Siblings
Grandparent
Other
Lazy/Crossed Eye
No
Parents
Siblings
Grandparent
Other
Review Of Systems
General
None
Fatigue
Fever
Loss of Appetite
Weight Gain
Weight Loss
Developmental Disorders
Other
Skin
None
Acne
Lupus
Dermatitis
Eczema
Psoriasis
Rosacea
Skin Cancer
Itching
Other
Ear/Nose/Throat
None
Neck Problems
Sinus Problems
Sore Throat (Recent)
Headache
Morning Headaches
Migraine Headache
Cluster Headache
Hearing Loss
Tinnitus
Congestion
Dry throat / mouth
Sleep Apnea
Other
Respiratory
None
Asthma
Cancer: lung
Sleep Apnea
Sarcoidosis
COPD
Emphysema
Pneumonia
Bronchitis
Shortness of breath
Wheezing
Other
Musculoskeletal
None
Arthritis
Osteoporosis
Fibromyalgia
Osteoarthritis
Muscular Dystrophy
Lupus
Decreased range of motion
Muscle cramps
Pain/tenderness
Stiffness
Swelling
Weakness
Other
Psychiatric
None
Attention Deficit Disorder
Anxiety
Brain Damage (trauma)
Panic Attacks
Alzheimer's Disease
Bi-polar
Depression
Insomnia
Obsessive/Compulsive
Paranoia
Suicidal
Violence
Other
Endocrine
None
Crohn's disease
Diabetes Type 1
Diabetes Type 2
Diabetes Suspect
Hypothyroid
Hyperthyroid
Gout
Hormone Replacement Therapy
Other
Blood/Lymph
None
Anemia
Hx of Significant Blood Loss
Hematologic Disorder
Sickle Cell Disorder
Breast Carcinoma
Lymph Node Disease
Temporal Arthritis
Cuts slow to clot
Easy bruising
Other
Neurological
None
Multiple Sclerosis
Seizure Disorder
Parkinson's Disease
Brain Tumor
Bells Palsy
Dyslexia
Headache
Balance problems
Vertigo
Tremors
Changes in senses
Dementia
Memory problems
Muscle weakness
Numbness, paralysis
Personality changes
Speech problems
Other
Immune
None
Seasonal allergies
Environmental allergies
Food allergies
Drug allergies (please specify)
Sjogren's syndrome
AIDS
Herpes Simplex
HIV Simplex
Mononucleosis
Tuberculosis
Cytomegalovirus Infection
Herpes Zoster
Lyme Disease
Sarcoidosis
Syphilis
Hives
Itching
Mild allergy symptoms
Severe allergy symptoms
Swelling
Other
Genitourinary
None
Amenorrhea
Menopause
Impotence
Jaundice
Uterine Cancer
Prostate Cancer
Kidney Stones
Pregnant
Nursing
Syphilis
Prostate Problems
Bladder Infections
STD- herpetic
STD- chlamydia
Other
Gastrointestinal
None
Acid Reflux
Crohn's disease
Gastric reflux (GERD)
IBS
Ulcer
Gall bladder problems
Jaundice
Hepatitis
Sarcoidosis
Cancer: colon
Cancer: Liver
Other
Cardiovascular
None
Congestive Heart Disease
Cardiovascular Disease
High Cholesterol
Hypertension
Arrhythmia
Heart Murmur
Heart Palpitation
Chest Pain
Arteriosclerosis
Coagulation Disorder
Mitral Valve Prolapse
Low Blood Pressure
Other
Social History
Hobbies
None
Art
Baseball
Astronomy
Boating
Basketball
Cooking
Crafts
Dancing
Diving
Football
Fishing
Golf
Gardening
Horseback Riding
Hunting
Models
Needlepoint
Painting
Photography
Piano
Reading
Running
Roller Blading
Softball
Sewing
Skiing
Soccer
Swimming
Tennis
Video Games
Woodworking
Other
Smoking Status
Never smoked (Less than 100 cigs equiv)
Former smoker (nolonger smokes)
Current some day smoker (not daily)
Light smoker (greater than 10cigs/day)
Heavy smoker (more than 10 cigs/day)
Smoker (current status unknown)
Current every day smoker
Unknown if ever smoked
Other
Type
None
Cigarettes
Chewing Tobacco
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How long
Alcohol Use
No
Yes
Occasionally
Socially
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Type
None
Beer
Wine
Hard Liquor
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How long
Illegal Drug Use
No
Yes
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Type
How long
Race
White
Black or African American
Asian
Patient Declined to Specify
American Indian orAlaska Native
NativeHawaiian or Other Pacific Islander
Other Race
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Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Unknown
Patient Declined to Specify
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Preferred Language
English
French
German
Spanish
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STD
None
Gonorrhea
Syphilis
Hepatitis
HIV
TB
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Date
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