Patient Form

Demographics

Title	First	Last	MI	Suffix	Nickname

Address Line 1:
Address Line 2:
City:	StateZipCode
Home Phone:		Work Phone:
Cell Phone:		Other Phone:
Email		Preferred Contact Method:
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status		Employer/School Name
Misc/Guardian

Billing Information Is The Billing Address the Same?

Title	First	Last	MI	Suffix

Address

City	State	ZipCode

Home Phone:
Work Phone:

COVID-19 Symptom History

Do you have a cough?	No	Yes
Do you have a fever now or have you in the past 3 days?	No	Yes
Are you experiencing shortness of breath?	No	Yes
Have you been in contact with someone with symptoms of COVID-19 in the past 14 days?	No	Yes

Medical History

Who is your primary care physcian?
Please list other doctors you currently see:
Please list eye medications you currently take:
Please list other medications you currently take:
Please list any non prescription (OTC) vitamins, medications, or supplements you currently take:
Please list medication allergies:
Please list any major injuries, surgeries, or hospitalizations:
Pregnant Or Nursing:

Social History

Height:	ft. in.
Weight:	lbs.
Smoking Status:
Alcohol:
Recreational Drugs:
Preferred Language:
Race:
Ethnicity:

Patient Ocular History

With your current glasses or contact lenses(if any), are you currently experiencing?								Do you have, or have you been told you have:
No Yes								No Yes
Blurred Vision								Glaucoma
Dry Irritated Eyes								Macular Degeneration
Floaters								Retinal Detachment
Flashes of Light								Lazy / Crossed Eyes
Double Vision								Cataract
Itching Eyes								Serious Eye Injury

Additional Eye History:
Other Current Symptoms:
Eye Surgery or Laser:	NoYes

Family Eye History

Glaucoma:	No	Yes
Macular Degeneration:	No	Yes
Retinal Detachment:	No	Yes
Crossed / Lazy eye:	No	Yes

Family Medical History

Please list serious medical conditions that occur in your family.

Review of Systems

Do you currently have problems in any of these areas? If yes, please explain.

GENERAL: Fever, Weight Loss, Weight Gain, Fatigue?	No
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat	No
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease	No
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD	No
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux	No
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, Impotence	No
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury	No
SKIN: Growths, Rashes, Acne	No
NEUROLOGICAL: Headaches, Migraines, Seizures	No
PSYCHIATRIC: Depression, Anxiety, Insomnia	No
ENDOCRINE: Thyroid, Diabetes	No
BLOOD/LYMPH: Anemia, Cholesterol, Bleeding Problems	No
IMMUNOLOGIC: Rheumatoid Arthritis, AIDS, Lupus	No
CANCER	No

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