Online Patient Forms

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Instructions

Please provide as much information as you can on both the Demographics and Medical History tabs before submitting the form. Please bring your insurance cards with you to your appointment.

Please fill out to the best of your ability.

Questions? Call us at (515) 278-1653


Demographics





Home Phone: Work Phone:
Other Phone:
Cell Phone: Preferred Contact Method:
Email
Birthday (xx/xx/xxxx) Occupation
Sex Male Female
Marital Status Employer/School Name
Misc/Guardian

Medical History



Please list other doctors you currently see:
Please list eye medications you currently take:
Please list other medications you currently take:
Please list any supplement or over-the-counter
medications you currently take:
Please list medication allergies:
Please list any major injuries or surgeries:
Pregnant Or Nursing?

Review of Systems

Do you currently have problems in any of these areas? If yes, please explain:

GENERAL: Chronic fever or fatigue, unexpected weight gain or loss     No
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth No
CARDIOVASCULAR: High BP, Heart disease, Vascular Disease No
RESPIRATORY: Asthma, Emphysema, COPD, Sleep apnea No
GENITAL, KIDNEY, BLADDER: Kidney disease, frequent urination No
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury No
SKIN: Skin cancer, rashes, Rosacea, Psoriasis No
NEUROLOGICAL: Headaches, migraines, seizures, MS, or other No
PSYCHIATRIC: Depression, Anxiety, Insomnia, Panic disorder No
ENDOCRINE: Thyroid, Diabetes, Pituitary No
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems No
IMMUNOLOGIC / ALLERGY: Rheumatoid, Lupus, Allergies, HIV+ No
GASTROINTESTINAL: IBS, Crohn's, frequent cramping No
CANCER: Current or prior No

Social History

Height:ft. in.
Weight: lbs.
Smoking status:
Alcohol:
Recreational Drugs:
Preferred Language:
Race:
Ethnicity:

Patient Ocular History

Are you currently experiencing?   Do you have, or have you been told you have:
Yes No   Yes No
Blurred vision   Glaucoma
Dry, irritated eyes   Macular Degeneration
Floaters   Retinal Detachment
Flashes of light   Lazy / Crossed eye
Double vision   Cataract
Itching eyes   Serious eye injury
Additional eye history:
Other current symptoms:
Eye Surgery or Laser: No Yes

Family Eye History

Glaucoma: No Yes
Macular Degeneration: No Yes
Retinal Detachment: No Yes
Lazy / Crossed eye: No Yes

Family Medical History

Please list serious medical conditions that occur in your family:

Lifestyle Eye History

Please tell us about your hobbies and sports activities:
Do your eyes get tired or your vision blurry when using a computer?

All Ready?