Online Patient Form

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Patient Information
Title First Last MI Suffix Nickname Pronoun
City: State/ZipCode

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

Medical History

Briefly describe the main reason for having an examination today:
Associated: Do you have any other symptoms related to this?
Other eye issues or problems

I currently wear glasses:Full-time Part-time
If part-time, how often/when?

I currently wear contacts:Full-time Part-time
If part-time, how often/when?
Soft Rigid Gas Permeable

Contact wearers: Are your lenses comfortable?

Current Brand:
What solution do you use?
What is your replacement schedule?
How old is your current pair?
Please list all eyedrops you use (OTC and Rx):
How often used?:

Do you have any of the following?

Eye Turn
Lazy Eye
Macular Degeneration
Retinal Detachment

Are you currently experiencing any of the following?
HeadachesEyes feel sandy/gritty
Blurred VisionFlashing Lights
Double VisionFloaters
Eyes "hurt or tired"Halos around lights
Bothered by light/sunFrequent Styes
Eyes frequently redEyes itch
Eyes BurnEyes 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?
Describe any visual symptoms from computer use:
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 feverArthritis
Multiple Sclerosis Diabetes
Thyroid problemsMigraines
High blood pressureStroke
Anemia Cancer
Physician's Name:
Last Visit Date:
How often do you consume alcohol:

Do you have: Hepatitis HIVSTDs

Who referred you to our office?

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

Does your family have a history of these diseases? Family history is unknown/adopted
Poor Vision? YesNo
Blindness? YesNo
Eye turn? YesNo
Lazy Eye? YesNo
Glaucoma? YesNo
Cataracts? YesNo
Cancer? YesNo
Diabetes? YesNo
High Blood Pressure? YesNo
Stroke? YesNo
Thyroid? YesNo
Other Inherited Disease? YesNo
Macular Degeneration? YesNo
Retinal Detachment/Disease? YesNo
How often do you smoke/use tobacco products?

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: