Online Patient Form

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Patient Information


Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer / School Name
Misc/Guardian

Who referred you to our office? If not referred, how did you hear about our office?

Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Medical History

Visual History

Main Reason for Visit:

More Indepth Description of Symptoms:

Condition: Blurriness? Aching? Pain?
Which Eye, Eye Part, or Part of Head if Headache?
How Long or When Did It Start? How Severe?
Timing: Consistent? Comes/Goes? Improving?
Does Anything Help?
Any Other Symptoms Related to This Complaint? (Hard to Drive or Read, etc?)

Any Other Eye Issues or Problems?

Do you have a history of any of the following?

   Yes  No
Cataracts  
Glaucoma  
Blindness  
Keratoconus  
   Yes  No
Macular Degeneration  
Retinal Detachment  
Eye Turn (Strabismus)  
Lazy Eye (Ambylopia)  

Are you currently experiencing any of the following?

   Yes  No
Blurred Vision  
Double Vision  
Flashing Lights  
Floaters  
Eyes Feel Dry  
   Yes  No
Eyes Itch  
Eyes Burn  
Eyes Tear  
Frequent Styes  
Headaches  
   Yes  No
Eyes Frequently Red  
Sandy/Gritty Eyes  
Hurt/Tired Eyes  
Halos around Lights  
Bothered by Light  

Other Eye Disease or Conditions:
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:

Please list all eyedrops you use (OTC and Rx): How often used?:

I currently wear glasses:    If part-time, how often/when?
I currently wear contacts:    If part-time, how often/when?

Contact Lens Wearers: Are your lenses comfortable? Yes No Current Brand:
Solution: Age of Present Lenses: Relacement Frequency:

Medical History

Primary Care Physician:

Systemic Medicines: No Current Medications
Drug Allergies: No Known Drug Allergies

Are you pregnant or nursing? Yes No

Do you have, or ever had, any CHRONIC problems in the following areas?

   Yes  No
Diabetes  
Multiple Sclerosis  
Migraines  
Thyroid Problems  
   Yes  No
Arthritis  
Allergies/Hay Fever  
Asthma  
Emphysema  
   Yes  No
High BP  
Stroke  
Anemia  
Cancer  

Social History

Preferred Language: Race: Ethnicity:

Smoking Status
Height ft. in.
Weight

Family History

Any history of the following in any family members (parents, grandparents, siblings, children?) Family history is unknown/adopted

   Yes  No  Relationship to Patient
Poor Vision   
Blindness   
Eye Turn   
Lazy Eye   
Glaucoma   
Cataracts   
Macular Degen   
Retinal Detach   
   Yes  No  Relationship to Patient
Cancer   
Diabetes   
High BP   
Stroke   
Thyroid Disease   
Other Inherited Disease   
If yes, what disease?  


Review of Systems

General: Ears/Nose/Throat:
Respiratory: Cardiovascular:
Skin: Genitourinary:
Neurological: Musculoskeletal:
Psychiatric: Allergic/Immune:
Endocrine: Gastrointestinal:
Blood/Lymph:

Submit Data

Optomap Authorization

Important Announcment From Your Doctor

Dr Bruce L. Manning and Associates is proud to provide our patients with the most highly advanced technology available in retinal sceening today! Our ability to view your internal retinal health is now dramatically improved with the Optomap.

We are concerned about retinal problems such as macular degeneration, glaucoma, retinal holes or detachments, and diabetic retinopathy (all of which can lead to partial loss of vision or blindness). Additionally, systemic diseases such as diabetes and high blood pressure can be detected during a retinal exam.

Early Detection Is Crucial!!

Optomap Provides:
  • An annual eye wellness scan
  • A much larger view (20X bigger) of the retina than our old fundus camera
  • An in depth view of the retinal layers (where disease can start)
  • The ability to show you your images today during your exam
  • A permanent record for your medical file, which gives your doctor
    comparisons for tracking and diagnosing potential eye disease


Optomap:
  • Is fast, easy, and comfortable
  • Will NOT require dilating drops (which result in blurred vision and sensitivity to light) and is NOT as bright a flash as our old fundus camera. (Dilation may still be required if a suspicious health risk is noted)


Because your insurance is designed to cover only a basic eye exam, it does not cover advanced screening tools such as the Optomap. The doctors at Dr. Bruce L. Manning and Associates would like for ALL of our patients to have an Optomap exam annually. The additional fee is only $29.




Patient Signature: Date: