Online Patient Form

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Patient Information

Title	First	Last	MI	Suffix	Nickname

Home Phone:		Work Phone:
Other Phone:
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

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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:No Meds Used

No Known Drug Allergies

Vitamins:

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?:

Review of Systems

Social History

Hobbies:

Race:

Ethnicity:

Preferred Language:

STD: