Online Patient Form
Demographics
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
City:
State/ZipCode
TX
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
UT
VT
VI
VA
WA
WV
WI
WY
Home Phone:
Work Phone:
Other Phone:
Alerts:
SSN
Email
Birthday
Occupation
Sex
Male
Female
Employment Status
Employed
Full-Time Student
Part-Time Student
Marital Status
Unknown
Single
Married
Separated
Divorced
Widowed
Child
Employer/School Name
Primary Doctor
Misc/Guardian
Billing Information
Is The Billing Address the Same?
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Address
City
State
ZipCode
TX
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
UT
VT
VI
VA
WA
WV
WI
WY
Home Phone:
Work Phone:
Medical History
Occupation:
Hobbies:
None Listed
Astronomy
Art
Baseball
Boating
Basketball
Cooking
Crafts
Dancing
Diving
Football
Fishing
Golf
Gardening
Horseback Riding
Hunting
Models
Needlepoint
None
Painting
Photography
Piano
Reading
Running
Roller Blading
Softball
Sewing
Skiing
Soccer
Swimming
Tennis
Video Games
Woodworking
Reason for Visit
Any Unusual symptoms ?
Last Eye Exam:
Never
1 year
2 years
3 years
4 years
Over 4 yrs
Doctor:
Primary Vision Correction:
None
Glasses DVO
Glasses NVO
Progressives
Contacts
Bifocals
Trifocals
Type of CL
Dailies
2 wk disposable
torics
RGP's
Multifocals
Do you sleep in your contacts?
yes, often
occasionally
never
no
Do you swim w/ CL's?
Yes
No
Prior Eye Injury/ Eye Surgery?
None
cataract surgery
Retinal surgery
Glaucoma surgery
Corneal transplant
Lasik
Radial Keratometry
Foreign body, outer eye
Penetrating foreign body
Eyelid tattoo / eyeliner
Muscle surgery
Other not listed
Eye Meds:
None
Alphagan
Xalatan
Travatan
Visine
Patanol
rewetting drops
Vigamox
Pred Forte
Alrex
Vigamox
Restasis
CURRENT MEDICAL CONDITIONS:
Good health
Arthritis
Asthma
Diabetes
HBP
Headaches
Heart Condition
HX Of Drug/Alcohol Abuse
Inflammatory Bowel Disease
Smoking
Seizure Disorder
Thyroid Disease
Diagnosed As HIV+
MIgraines
Cancer
Hepatitis
Pregnant
Nursing
Blood or heart problems
None
High BP
Surgery
Vascular Disease
Thyroid, Diabetes
None
diabetes
hypothyroid
hyperthoyroid
Allergies, Sinus, Cough
None
Allergies
Sinus Problems
Chronic Cough
Dry Throat / Mouth
Hard of Hearing
Asthma, Bronchitis, Emphysema
None
Asthma
Bronchitis
Emphysema
COPD
Arthritis, joint pain
None
joint pain
stiffness
swelling
cramps
arthritis
Diarrhea, Constipation, Ulcer, Reflux
None
stomach upset
diarrhea
constipation
hernia
ulcers
Infection, Inflammation, Pain
None
painful urination
frequent urination
impotence
yellow jaundice
Headaches, Numb, Dizzy, Seizures
None
numbness, paralysis
Dizziness
headache
seizures
migraines
Rheumatoid arthritis, HIV/AIDS, Lupus, Sarcoidosis
None
lupus
HIV
AIDS
RHEUMATOID ARTHRITIS
Depression, Anxiety, Insomnia
None
anxiety
depression
insomnia
Skin Growths, Rashes, or Acne
None
pimples, warts
growths
rash
Fever, weight loss/gain, fatigue?
None
Yes
Negative
Anemia or blood disorders
None
bleeding
cholestrolemia
anemia
Previous Injuries / Surgeries :
None
Heart By-pass
Heart Stent
Thyroidectomy
Hysterectomy
Masectomy
Hernia repair
Other not listed
Your Physician:
Last Visit:
1 week
1 month
3 months
6 months
1 year
>1yr
2 years
More than 2 years
Are you Pregnant or Nursing?
No
Yes
Unsure
MEDICATIONS:
Drug Allergies:
OTC
Vitamins
Alcohol Use
No
Yes
Occasionally
Socially
Tobacco Use
No
Yes
Mental Status
Alert
Aware / Responsive
Mild pain
Moderate pain
Extensive pain
Distressed
Anxious
Beligerant
Disoriented
Illegal Drugs?
No
Yes
FAMILY HISTORY:
No problems known
Adopted
Diabetes
HBP
Cancer
Cardiovascular Disease
Athritis
Kidney Disease
Lupus
Thyroid
Glaucoma
Cataracts
Macular Degeneration
Retinal disorder or detachment
Cataracts
None
Self
Parent
Grandparent
Sibling
Aunt
Uncle
Cousin
Macular Degeneration
None
Self
Mother
Father
Grandparent
Sibling
Aunt
Uncle
Glaucoma
None
self
Mother
Father
Grandparents
Sibling
Retinal Detachment
None
Self
Grandparents
Parents
Siblings
Crossed / Lazy Eye
None
Self-Right Eye
Self-Left Eye
Grandparents
Parents
Siblings
Blindness
None
Parent
Grandparent
Sibling
Aunt
Uncle
Diabetes
Other:
HTN
Cancer
OTHER: