Online Patient Form
After completing the 'Demographics' and 'Medical History' info, please submit your data on the final tab. Thank you!
Demographics
Patient Information
First*
Last*
MI
Suffix
Nickname:
Address:
Apt/Ste:
City:
State:
AZ
AL
AK
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
Zip Code:
Email*:
Home Phone*
Cell Phone
Preferred Contact
Text Message
Cell Phone
Email
Home Phone
SSN
Birthday*
Sex
Male
Female
Employment Status:
Employed
Full-Time Student
Part-Time Student
Occupation
Employer / School Name
Parent or Guardian:
Is the Billing Address Different?
Billing Information
First
Last
MI
Suffix
Copy Address From Above
Address
City
State
ZipCode
AZ
AL
AK
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
Home Phone:
Work Phone:
How did you hear about Pearson Eyecare West?
Family member
Insurance list
Coworker
Friend
Primary Care Doctor
Internet
Drove by
Medical History
Reason for Visit
Are you currently experiencing any of the following?
Check all that apply.
SET ALL TO NO
NO
YES
Blurred Vision
NO
YES
Double Vision
NO
YES
Eyes Itch
NO
YES
Eyes Burn
NO
YES
Eyes Tearing
NO
YES
Headaches
NO
YES
Floaters
NO
YES
Flashing Lights
Medical History
List all medications you are currently taking (including any OTC/vitamins):
No current medication
List any medications you are allergic to:
No known drug allegies
List any eye surgeries:
List any eye injuries:
How often do you smoke/use tobacco products?
Never smoker (<100 lifetime cigarettes or equivalent)
Former smoker (no longer smokes)
Current some day smoker (not daily)
Light smoker (<10 cigs/day)
Heavy smoker (>10 cigs/day)
Do you have a history of any of the following?
Check all that apply.
SET ALL TO NO
NO
YES
Blindness
NO
YES
Eye Turn (Strabismus)
NO
YES
Lazy Eye (Amblyopia)
NO
YES
Keratoconus
NO
YES
Glaucoma
NO
YES
Cataracts
NO
YES
Macular Degeneration
NO
YES
Retinal Detachment
NO
YES
Cancer
NO
YES
Diabetes
NO
YES
High Blood Pressure
NO
YES
Stroke
NO
YES
Thyroid Disease
Family History
Family history is unknown/adopted
Does a family member have a history of any of the following?
Check all that apply.
SET ALL TO NO
NO
YES
Mother
Father
Both Parents
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Blindness
NO
YES
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Eye Turn (Strabismus)
NO
YES
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Lazy Eye (Amblyopia)
NO
YES
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Glaucoma
NO
YES
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Cataracts
NO
YES
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Macular Degeneration
NO
YES
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Retinal Detachment
NO
YES
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Cancer
NO
YES
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Diabetes
NO
YES
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
High Blood Pressure
NO
YES
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Stroke
NO
YES
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Thyroid Disease
Submit Data