Online Patient Form

Patient Information

Billing Information

Insurance Information

General Medical History

Review of Systems

Ocular History

Click here to return to the previous website.

After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!

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

Is The Billing Address the Same? Yes

Title	First	Last	MI	Suffix

Address:

City:	State:	Zip Code:
Home Phone:
Work Phone:

Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Primary physician's name and phone
When was your last physical exam?

Check the box for any conditions that apply to you, your parents or siblings:

If YOU are diabetic, when were you diagnosed?

Last A1C level?

Are you Pregnant or Nursing?

List ALL major injuries or surgeries you have had and approx dates:

List any other medical conditions you have had, including non-drug allergies:

List all Rx and over-the-counter medications you currently take:

List any vitamins or supplements you currently take:

List any drug allergies you have:

Smoking Status
Alcohol Use
Do you live alone?

Please list any problems you are currently having anywhere, from head to toe:

General (e.g., fever, fatigue, loss of appetite, unexplained weight loss/gain)

Ear, Nose, Throat (e.g., sinus/nasal congestion, nose bleeds, dry mouth/throat, sleep apnea, hearing problems)

Cardiovascular (e.g., chest pain, racing heartbeat, swollen feet/ankles, TIAs)

Respiratory (e.g., chronic cough, shortness of breath, wheezing)

Genital, Kidney, Bladder (e.g., bladder/urinary problems, pain, discharge, menstrual changes, impotence)

Gastrointestinal (e.g., constipation, diarrhea, gastric reflux (GERD), jaundice, nausea, vomiting)

Endocrine (e.g., heat or cold intolerance, thinning hair, excess thirst, excess urination)

Muscles, Bones, Joints (e.g., pain, stiffness, swelling, weakness, limited movements)

Skin (e.g., dry, itchy, flaky, rash, growths, bumps, redness, discoloration)

Neurological (e.g., headaches, numbness/tingling, tremors, poor balance, dementia, speech problems)

Psychiatric (e.g., depression, anxiety, sleep problems, paranoia, obsessive/compulsive)

Blood/Lymph (e.g., anemia, bleeding gums, delayed clotting, unexplained bruising)

Allergy/Immune (e.g., swollen lymph nodes, itching, sneezing, runny nose/eyes)

Describe (type, when were you diagnosed, etc)

Hypertension

Cardiovascular

Check the box for any conditions that apply:

List any major eye injuries, infections or surgeries and approx dates:

List any other significant eye problems you have had:

List all Rx and over-the-counter eye medications you currently use:

List any vision complaints you are currently having such as:

blurred vision, headaches, eyestrain, double vision, or losing your place when reading
itching, burning, redness, pain, sensitivity to light, watering, crusting or mucus discharge
seeing rainbows around white lights at night, flashes of light or dark spots/squiggles/webs

How many hours/day do you typically spend using a computer or other digital devices?
If you are having complaints with computer work, how far is the monitor from your eyes?
How many hours/day do you typically spend reading books, magazines, etc?

What are your hobbies/sports activities?
Do you have sunglasses?
Do you have back-up glassess?
Are you interested in contacts?