Online Patient Form
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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?
Yes
No
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
HIV
STDs
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
Click here for Privacy Policy
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: