Online Patient Forms

Patient information

First name

*This field is required

Last name

*This field is required

Nickname

Birth Sex

Male Female

*This field is required

Address

Apt/Suite #

City

State

Zip Code

Cell Phone

*This field is required

Home Phone

Preferred Contact Method

Birthday

SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Pronoun

Gender Identity

Marital Status

Misc/Guardian

Authorized persons to release medical information to:

Billing information

Is The Billing Address Different? Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Vision Insurance

Insurance Information

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account: Not Primary

Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Birth Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Primary Medical Insurance

Insurance Information

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account: Not Primary

Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Secondary Medical Insurance

Insurance Information

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account: Not Primary

Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Please choose from the menu options or select the option to type in your own text. Thank you!

Visual History

Breifly describe the main reason for having an examination today

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?

What type of contacts do you wear?

Soft

Rigid Gas Permeable

Are your contact lenses comfortable?

Yes

Current Brand

What solution do you use?

Replacement schedule?

How old is your current pair?

Please list all eyedrops you use (OTC and Rx)

How often do you use the drops?

Do you have a history of any of the following? SET ALL TO NO	YES	NO
Blindness
Eye Turn (Strabismus)
Lazy Eye (Amblyopia)
Keratoconus
Glaucoma
Cataracts
Macular Degeneration
Retinal Detachment
Headaches
Blurred Vision
Double Vision
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
Eyes feel sandy/gritty
Flashing lights
Floaters

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

Medical History

Primary Care Physician's Name

Last Visit Date

List all medications you are currently taking (including any OTC/vitamins)

List any medications you are allergic to

Are you pregnant or nursing?

Yes

If yes, what is the due/birth date?

Do you have, or ever had, any CHRONIC problems in the following areas? SET ALL TO NO	YES	NO
Migraines
Multiple Sclerosis
Diabetes
Thyroid problems
Arthritis
Allergies/Hay fever
Asthma
Emphysema
High blood pressure
Stroke
Anemia
Cancer
High Cholesterol
Weight Changes
Gastrointestinal Problems
Skin Problems
Sinus Problems

Are you interested in contact lenses?

Are you interested in purchasing glasses today?

Are you interested in Lasik?

How often do you smoke/use tobacco products?

How often do you consume alcohol?

Do you have?

Hepatitis

HIV

STDs

Do you have a history of any of the following in your family? (Grandparents, Parents, Siblings) SET ALL TO NO Family history is unknown/adopted	YES	NO
Poor vision
Blindness
Eye turn (Strabismus)
Lazy Eye (Amblyopia)
Glaucoma
Cataract
Macular Degeneration
Retinal Detachment/Disease
Cancer
Diabetes
High Blood Pressure
Stroke
Thyroid Disease
Other inherited disease

If yes to other inherited disease, what disease?

Who referred you to our office?

If not referred, how did you hear about Belleview Eye Associates?