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: