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

SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Marital Status

Misc/Guardian

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Medical History

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Eye History

Reason for your visit

Medical History 1

Medical History 2

Medical History 3(Free type)

Height

Ft:

in:

Weight

Please list all drug allergies:

Have you been diagnosed with Diabetes?

If diabetic, what was the last blood sugar reading?

When was your Blood sugar reading taken?

What was your HbA1C reading?

Are you pregnant or nursing?

Have you had a tetanus shot within the last 5 years?

Primary Care Physician

Last visit

Other Physician

Preferred Language Ethnicity Race Occupation Hobbies

Smoking Status

Type

Last Eye Doctor

Last Eye Exam

Primary Vision Correction

Are you planning to get new glasses?

Do you have back up glasses?

Do you have a good pair of sunglasses?

Do you wear contacts?

Brand of contacts right eye

Brand of contacts left eye

Contact solution used

How often do you replace your contacts?

When are you bothered by glare?

Patient Ocular/Vision History

Please select if you had any of the following symptoms(Please select yes no or unsure for every question)

Blurry Distance Vision	Stye/Chalazion	Dry Eye Disease or Ocular Surface Disease
Blurry Near Vision	Floaters	Cataracts
Redness	Loss of Side Vision	Macular Degeneration
Burning/Stinging	Distorted Vision	Glaucoma
Itching	Halos	Retinal Disease/ Disorder
Excess Tearing/Watering eyes	Drooping Eyelid	Retinal Detachment
Sandy/Gritty feeling	Eye Pain	Strabismus(Eye Turn)
Glare/Light sensitivity	Prominent Eyes(Protruding Eye)	Amblyopia(Lazy Eye)
Have you ever had punctal occlusion (Punctal plugs)?

Medications

Prescription eye drops for Dry Eye Syndrome(e.g. Restasis)

If Yes, Brand of Medication:

Prescription eye drops for Glaucoma(e.g. Xalatan, Timolol)

If Yes, Brand of Medication:

Prescription eye drops of Allergies(e.g. Pataday, Alaway)

If Yes, Brand of Medication:

Prescription corticosteroids(e.g Prednisone)

If Yes, Brand of Medication:

Prescription Antihypertensives/blood pressure(e.g. diuretic, beta-blocker)

If Yes, Brand of Medication:

Prescription antidepressants or anti-anxiety(e.g. Paxil, Prozac, Xanax)

If Yes, Brand of Medication:

Prescription Hormone replacement therapy or estrogen(e.g. Premarin)

If Yes, Brand of Medication:

Any Nutritional Supplements(e.g. Flaxseed/fish oil, omega3)

If Yes, Brand of Medication:

Any over the counter eye drops such as artificial tears

If Yes, Brand of Medication:

Review Of Systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Family Medical History

Unknown family history

Does anyone in your family have any of these medical conditions?

Diabetes

Glaucoma

Asthma

Retinal Problems

COPD

Thyroid Disease

Seizure Disorder

Arthritis

Kidney Disease

Hypertension

Cancer

Heart Disease

Back Problems

Headaches

High Cholesterol

Inflammatory Bowel Disease

Lupus

Patient information

Billing information

Primary Vision Insurance

Primary Medical Insurance

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Medical History

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Eye History

Patient Ocular/Vision History

Medications

Review Of Systems

Family Medical History

Does anyone in your family have any of these medical conditions?