Online Patient Form

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Patient Information

City: State: Zip Code:
Home Phone: Work Phone:
Other Phone:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name

Medical History

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Eye History

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:
Have you had any eye surgeries? Please describe:
Last Eye Exam: By Doctor:

Do you:

Have back up glasses? Want new glasses?
Want Contacts?:Age of Current Glasses?:

Contact Lens Wearers only

Current Contact Lens Brand: Solutions:
Power OD: Power OS:
How Often Do You Change Your Contacts?: Days Per Week Worn:
Hours Per Day Worn: How is Your Vision With Contacts?:
Rate Your End of The Day Comfort X/10:

Medical History

All current prescription medications will be noted on at the time of visit.

Over The Counter Medications:
Please describe any injuries or surgeries you have had:

Height: FT IN
Weight: LB

Primary Care Physician: Last Visit: Reason:
Pregnant Or Nursing: Recent Tetanus Shot:

Family Medical History

Family Medical History (Adopted, Diabetes, High Blood Pressure, Cancer, Lupus, Thyroid, Cardiovascular Disease etc)
Family Medical History 2 (Diabetes, High Blood Pressure, Cancer, Lupus, Thyroid, Cardiovascular Disease etc)

Family Eye History

Does anyone in your family have any of these eye conditions?:

Macular Degen: Glaucoma:
Retinal Detach: Cataracts:
Lazy/Crossed Eye: Blindness:

Review of Systems

General: Ear/Nose/Throat:
Skin: Cardiovascular:
Respiratory: Musculoskeletal:
Psychiatric: Gastrointestinal:
Endocrine: Blood/Lymph:
Neurological: Genitourinary:

Social History


Smoking Status: Type: How Long:
Alcohol Use: Type: How Long:
Illegal Drug Use: Type: How Long

Race: Ethnicity: Preferred Language:

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