Online Patient Forms

Patient information

First name

*This field is required

Last name

*This field is required

Nickname

Birth Sex

Male Female

Address

Apt/Suite #

City

State

Zip Code

Cell Phone

*This field is required

Home Phone

Preferred Contact Method

Birthday

Last 4 of SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Pronoun

Gender Identity

Marital Status

Misc/Guardian

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:

Primary 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

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 type in your own text. Thank you!

Eye History

Chief Complaint

Encounter Type

Last Eye Exam

Place of Occurrence

External Cause

Other Issues / Notes

Do you currently wear glasses?

Full time

Part time

If part-time, how often/when?

Outdoor Activities / Sports

Do you currently wear contacts?

Full time

Part time

If part-time, how often/when?

Hobbies

Do you have sunglasses?

Yes

OTC

Rx Sun

Do you have a history of any of the following?

Disease/Condition	Yes	No
Blindness
Eye turn (Strabismus)
Lazy eye (Amblyopia)
Keratoconus
Macular Degeneration
Retinal Detachment
Glaucoma
Cataracts

Are you currently experiencing any of the following?

Disease/Condition	Yes	No
Headaches
Blurred Vision
Double Vision
Eyes "hurt" or "tired"
Floaters
Flashing Lights
Eyes feel sandy/gritty
Eye Pain
Discharge
Halos around lights
Bothered by light/sun
Frequent styes
Eyes are frequently red
Eyes itch
Eyes burn
Eyes tear
Eyes feel dry

List any eye surgeries:

Describe any eye injuries

Other eye disease or condition

How many hours a day do you use a computer?

Describe any visual symptoms from computer use:

Medical History

Physician's Name:

Last Visit Date:

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

Allergies/Alerts:

Height

Ft.

In.

Weight

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

How often used?:

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?

Disease/Condition	Yes	No
Migraines
Multiple Sclerosis
Diabetes
Thyroid problems
Arthritis
Allergies/Hay fever
Asthma
Emphysema
High blood pressure
Stroke
Anemia
Cancer
High Cholesterol

Influenza Immunization

Pneumonia Vaccination (over 65 y.o.)

Family History

Any history of the following in any family members (parents, grandparents, siblings, children)?

Disease/Condition	Yes	No	Relationship to You
Poor Vision
Blindness
Eye Turn (Strabismus)
Lazy Eye (Amblyopia)
Glaucoma
Cataracts
Macular Degeneration
Retinal Detachment/Disease
Cancer
Diabetes
High Blood Pressure
Stroke
Thyroid Conditions
Other Inherited Disease

If yes, what other disease?

Social History

How often do you smoke/use tobacco products?

How often do you consume alcohol:

Do you have?

Hepatitis

HIV

STDs

Occupation:

Employer:

Who referred you to our office?

If not referred, how did you hear about the Patterson Eye Clinic?