Online Patient Forms

Patient information

First name

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Last name

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Nickname

Birth Sex

Male Female

Address

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Apt/Suite #

City

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State

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Zip Code

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Cell Phone

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Home Phone

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Preferred Contact Method

Birthday

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Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Misc/Guardian

Billing information

Is The Billing Address Different? Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

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Routine Eye Care Health History

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Eye History

Do you experience, or have you experienced any of the following? (Check all that apply from the drop-down list)

Do you currently take any of these medications?

Have you had any of the following? (check all that apply from the drop-down list)

Last Eye Exam

Last Appointment Type

By Doctor

Primary Vision Correction

Do you:

Have Backup Glasses?

Want New Glasses?

Contact Lens Wearers only:

Type of Contacts worn in the past

Cleaner

Disposal

Wear Time

Medical History:

Medications - Please list all prescription medications you are taking. No Medications

Over the Counter Medications - Please list any over the counter medication you are taking; for example - ibuprofen, acetaminophen, etc.

Vitamins - Please list any vitamins/minerals you are taking.

Drug allergies - Please list any medications that you are allergic to or have had an adverse reaction.

Please Describe any Injuries or Surgeries you have had

Primary Care Physician

Last Visit

Reason

Pregnant or Nursing

Recent Tetanus Shot

Recent Flu Immunization

Please choose the appropriate response from the drop-down list. Where there is no drop-down, please type in the appropriate response.

Diabetes

High Blood Pressure

High Cholesterol

Thyroid Conditions

Heart Conditions

Cancer

Year Diabetes Diagnosed

Other

Family Medical History

Unknown Family History

Has anyone in your family, living or deceased, ever been diagnosed with the following?
If Yes, please indicate which family member in the drop-down list it applies. (M = Mother, F = Father, Sibling, GM = Grandmother, GF = Grandfather, Unknown)

High Blood Pressure

Diabetes

Thyroid

Cancer

High Cholesterol

Heart Conditions

Other

Family Eye History

Has anyone in your family, living or deceased, ever been diagnosed with the following?
If Yes, please indicate which family member in the drop-down list it applies. (M = Mother, F = Father, Sibling, GM = Grandmother, GF = Grandfather, Unknown)

Macular Degen

Glaucoma

Retinal Detach

Blindness

Cataracts

Lazy/Crossed Eye

Review Of Systems

Do you experience, or have you experienced any of the following? (Check all that apply from the drop-down list)

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Social History

Please choose the appropriate response from the drop-down list. Where there is no drop-down, please type in the appropriate response.

Hobbies

Smoking Status

Type

How long

Alcohol Use

Type

How long

Illegal Drug Use

Type

How long

Race

Ethnicity

Preferred Language

STD

Patient information

Billing information

Please choose from the menu options or select the option to type in your own text. Thank you!

Routine Eye Care Health History

Please choose from the menu options

Eye History

Contact Lens Wearers only:

Medical History:

Please choose the appropriate response from the drop-down list. Where there is no drop-down, please type in the appropriate response.

Family Medical History

Has anyone in your family, living or deceased, ever been diagnosed with the following?
If Yes, please indicate which family member in the drop-down list it applies. (M = Mother, F = Father, Sibling, GM = Grandmother, GF = Grandfather, Unknown)

Family Eye History

Has anyone in your family, living or deceased, ever been diagnosed with the following?
If Yes, please indicate which family member in the drop-down list it applies. (M = Mother, F = Father, Sibling, GM = Grandmother, GF = Grandfather, Unknown)

Review Of Systems

Do you experience, or have you experienced any of the following? (Check all that apply from the drop-down list)

Social History

Please choose the appropriate response from the drop-down list. Where there is no drop-down, please type in the appropriate response.

Specialty Clinic Information

Neuro-Optometry Health History

Background

Initial Treatment

Current Providers

Symptoms

For the following section, please enter the most appropriate number that best matches your observations

0-Never | 1-Seldom | 2-Occasionally | 3-Frequently | 4-Always

Eyesight Clarity

Visual Comfort

Doubling

Light Sensitivity

Dry Eyes

Depth Perception

Peripheral Vision

Reading

Auditory

Vestibular

Attention

Sleep

Proprioceptive/Kinesthetic

EMPLOYMENT / EDUCATION INFORMATION (if applicable)

Patient information

Billing information

Please choose from the menu options or select the option to type in your own text. Thank you!

Routine Eye Care Health History

Please choose from the menu options

Eye History

Contact Lens Wearers only:

Medical History:

Please choose the appropriate response from the drop-down list. Where there is no drop-down, please type in the appropriate response.

Family Medical History

Has anyone in your family, living or deceased, ever been diagnosed with the following? If Yes, please indicate which family member in the drop-down list it applies. (M = Mother, F = Father, Sibling, GM = Grandmother, GF = Grandfather, Unknown)

Family Eye History

Has anyone in your family, living or deceased, ever been diagnosed with the following? If Yes, please indicate which family member in the drop-down list it applies. (M = Mother, F = Father, Sibling, GM = Grandmother, GF = Grandfather, Unknown)

Review Of Systems

Do you experience, or have you experienced any of the following? (Check all that apply from the drop-down list)

Social History

Please choose the appropriate response from the drop-down list. Where there is no drop-down, please type in the appropriate response.

Specialty Clinic Information

Neuro-Optometry Health History

Background

Initial Treatment

Current Providers

Symptoms

For the following section, please enter the most appropriate number that best matches your observations

0-Never | 1-Seldom | 2-Occasionally | 3-Frequently | 4-Always

Eyesight Clarity

Visual Comfort

Doubling

Light Sensitivity

Dry Eyes

Depth Perception

Peripheral Vision

Reading

Auditory

Vestibular

Attention

Sleep

Proprioceptive/Kinesthetic

EMPLOYMENT / EDUCATION INFORMATION (if applicable)

Has anyone in your family, living or deceased, ever been diagnosed with the following?
If Yes, please indicate which family member in the drop-down list it applies. (M = Mother, F = Father, Sibling, GM = Grandmother, GF = Grandfather, Unknown)

Has anyone in your family, living or deceased, ever been diagnosed with the following?
If Yes, please indicate which family member in the drop-down list it applies. (M = Mother, F = Father, Sibling, GM = Grandmother, GF = Grandfather, Unknown)