Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname	Pronoun
Mr. Mrs. Ms. Dr. Rev. Fr. Miss						he/him/his she/her/hers they/them/theirs

Address:
City:		State/ZipCode	TN KY

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Text Message Cell Phone Email Work Phone Home Phone Other Phone
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed	Employer / School Name
Misc/Guardian

Is the Billing Address Different?

Billing Information

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Copy Address From Above
Address

City	State	ZipCode
	TN KY

Home Phone:
Work Phone:

Medical History

Briefly describe the main reason for having an examination today:

Associated: Do you have any other symptoms related to this?

none dizzy headache loss of vision blurred vision Other

Other eye issues or problems

I currently wear glasses:Full-time Part-time

If part-time, how often/when?

Occasionally Driving Reading / Computer After contact lens removal 1-2 times per week Half time Sports Weekends Social activities Other

I currently wear contacts:Full-time Part-time

If part-time, how often/when?

Occasionally Driving 1-2 times per week Half time Sports Weekends Social activities Other

Soft Rigid Gas Permeable

Contact wearers: Are your lenses comfortable?
YesNo

Current Brand:

Acuvue 1-day Acuvue 1-day Moist Acuvue 1-day Trueye Acuvue 2 Acuvue Oasys Acuvue Oasys for Astigmatism Acuvue Oasys for Presbyopia Acuvue Advance Acuvue Advance for Astigmatism Air Optix Air Optix Night & Day Air Optix Astigmatism Air Optix Multifocal Avaira Biomedic Toric Biomedic XC Biofinity Biofinity Toric Biofinity Multifocal Clearsight 1 day Clearsight 1 day Toric Focus Dailies Standard Focus Dailies AC plus Focus Dailies Toric Frequency 55 Frequency 55 Toric Frequency 55 Aspheric Freshlook colorblends Proclear Proclear 1 day Proclear EP Proclear Multifocal Purevision Purevision 2 Purevision 2 Toric Purevision Multifocal Soflens 38 Soflens Toric Soflens Daily Disposable Soflens Multifocal Vertex Toric Boston EO Boston ES Boston XO Fluoroperm 60 Menicon Z Thin RGP - unknown material Other

What solution do you use?

None Optifree Replenish Optifree Pure Moist Optifree Express Renu Biotrue Clear Care Kirkland Signature Revitalens Generic store brand Boston Advance Boston original Optimum B & L Gas Perm Unique Ph Other

What is your replacement schedule?

Daily Weekly Every 2 weeks Monthly If they feel bad Quarterly Yearly Other

How old is your current pair?

new 1-2 weeks 2-4 weeks very old Other

Please list all eyedrops you use (OTC and Rx):

none Blink Genteal Optive Refresh Plus Similisan Systane Generic artificial tears Murine Visine Lumigan Travatan Xalatan Timoptic Other

How often used?:

daily occasionally rarely Other

Do you have any of the following?

Blindness
Eye Turn
Lazy Eye
Keratoconus
Macular Degeneration
Retinal Detachment
Glaucoma
Cataracts

Are you currently experiencing any of the following?

Headaches		Eyes feel sandy/gritty
Blurred Vision		Flashing Lights
Double Vision		Floaters
Eyes "hurt or tired"		Halos around lights
Bothered by light/sun		Frequent Styes
Eyes frequently red		Eyes itch
Eyes Burn		Eyes tear
Eyes feel dry

Other eye disease or condition

Describe any eye injuries:

List any eye surgeries:

How many hours a day do you use a computer?

<2 hours 2 - 4 hours 5 - 8 hours 9 - 12 hours 12+ hours Other

Describe any visual symptoms from computer use:

none Eye strain Blurred vision Headache Dry eyes Watery Itch Burn Double vision Other

Are you pregnant or nursing? Yes No If yes, what is the due/birth date?

Do you have, or ever had, any CHRONIC problems in the following areas?

Allergies/Hay fever		Arthritis
Asthma		Emphysema
Multiple Sclerosis		Diabetes
Thyroid problems		Migraines
High blood pressure		Stroke
Anemia		Cancer

Notes:

BMI

Weight

Physician's Name:

Deborah Woods Fast Pace Jason Hollingsworth Ken Berry Lynn Dicus McKenzie Medical Center Steve Canady Terry Harrison Verneda Herring Other

Last Visit Date:

How often do you consume alcohol:

Never Occasionally Daily Other

Do you have: Hepatitis HIVSTDs

Who referred you to our office?

If not referred, how did you hear about The Eyecare Center?

Family member Insurance list Coworker Friend Primary Care Doctor Internet Drove by Other

Does your family have a history of these diseases? Family history is unknown/adopted

Poor Vision?

Yes

No

Mother Father Sister Brother Aunt Uncle Parents Grandparent(s) Other

Blindness?	Yes		No	Mother Father Sister Brother Aunt Uncle Parents Grandparent(s) Other

Eye turn?	Yes		No	Mother Father Sister Brother Aunt Uncle Parents Grandparent(s) Other

Lazy Eye?	Yes		No	Mother Father Sister Brother Aunt Uncle Parents Grandparent(s) Other

Glaucoma?	Yes		No	Mother Father Sister Brother Aunt Uncle Parents Grandparent(s) Other

Cataracts?	Yes		No	Mother Father Sister Brother Aunt Uncle Parents Grandparent(s) Other

Cancer?	Yes		No	Mother Father Sister Brother Aunt Uncle Parents Grandparent(s) Other

Diabetes?	Yes		No	Mother Father Sister Brother Aunt Uncle Parents Grandparent(s) Other

High Blood Pressure?	Yes		No	Mother Father Sister Brother Aunt Uncle Parents Grandparent(s) Other

Stroke?	Yes		No	Mother Father Sister Brother Aunt Uncle Parents Grandparent(s) Other

Thyroid?	Yes		No	Mother Father Sister Brother Aunt Uncle Parents Grandparent(s) Other

Other Inherited Disease?	Yes		No	Mother Father Sister Brother Aunt Uncle Parents Grandparent(s) Other

Macular Degeneration?	Yes		No	Mother Father Sister Brother Aunt Uncle Parents Grandparent(s) Other

Retinal Detachment/Disease?	Yes		No	Mother Father Sister Brother Aunt Uncle Parents Grandparent(s) Other

Occupation:

Employer:

How often do you smoke/use tobacco products?

Never Occasionally Daily Other

Signatures/Submit Data

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I have read and agree to the above policy:
Patients E-Signature: Date:

Click here for Patient Responsibility

Optomap Retinal Exam:
Our doctors highly recommend that you have an Optomap Retinal Exam. The Optomap is a comprehensive method of evaluating, monitoring, and helping treat various eye conditions.
There will be a $30.00 charge for this service that insurance will not cover.

Yes, Optomap approved

Not sure, need to discuss.

I have read and agree to the above policy:

Patients E-Signature: Date: