Online Patient Forms

Patient information

First name

*This field is required

Last name

*This field is required

Nickname

Birth Sex

Male Female

Address

*This field is required

Apt/Suite #

City

*This field is required

State

*This field is required

Zip Code

*This field is required

Cell Phone

*This field is required

Home Phone

*This field is required

Preferred Contact Method

Birthday

*This field is required

SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Pronoun

Gender Identity

Marital Status

Misc/Guardian

Billing information

Is The Billing Address Different? Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Please choose from the menu options or select the option to type in your own text. Thank you!

Visual History

VISUAL NEEDS HISTORY

Date

Nickname

Last Eye Exam

Age

Insurance #1

Insurance #2

Location of Last Eye Exam:

Hobbies

Race

Preferred Language

Physician's Name:

Preferred Pharmacy

Glasses Pair 1:

Glasses Pair 2:

Glasses Pair 3:

Glasses Pair 4:

Glasses Pair 5:

Glasses Prescription Up To Date?

MEDICAL EYE HISTORY

No Changes To Medical History

Have You Been Diagnosed With Any Of The Following Conditions?

Eye Turn (Strabismus):

Keratoconus:

Low Macular Pigment Density (MPOD):

Diabetic Retinopathy:

Blepharitis:

Amblyopia (Lazy Eye):

Retinal Hole:

Epiretinal Membrane:

Hypertensive Retinopathy:

Melbomian Gland Dysfunction (MGD):

Cataracts:

Retinal Detachment:

Lattice Degeneration:

Iritis / Uveitis / Iridocyclitis:

Stye / Hordeolum:

Glaucoma:

Macular Degeneration:

Posterior Vitreous Detachment (PVD):

Preseptal / Orbital Cellulitis:

Dry Eye Disease:

Have You Experienced Any Of The Following Symptoms In The Last 30 Days?

Blurred Vision At Distance:

Itchy Eyes:

Tired Eyes (Eye Fatigue):

Halos Around Lights:

Double Vision:

Dry, Gritty, Or Burning Sensation:

Glare At Nighttime:

Do You Have History Of Any Of The Following Eye Treatments Or Therapies?

Vision Therapy:

Ortho-K / CRT Contacts:

Myopia Management:

Blue Light Blocking Lenses:

Punctal Plugs / Punctal Occlusion:

Zeaxanthin / Lutein Supplementation:

LipiFlow:

Fish Oil / OMEGA-3 Supplementation:

Have You Had Any Of The Following Eye Surgeries Performed?

Cataract Surgery:

Corneal Transplant:

Trabeculoplasty:

LASIK:

Corneal Cross-Linking (CXL):

Glaucoma Laser Procedure (SLT/ALT):

PRK:

Retinal Laser:

Iris Laser:

RK:

Avastin / Lucentis Injections:

Blepharoplasty:

Eye Disease Not Listed:

Eye Surgeries Not Listed:

Eye Injuries:

Other Notes On Visual History:

MEDICAL HISTORY

PERSONAL MEDICAL HISTORY

Last Health Exam:

Medication Allergies:

No Known Drug Allergies

Current Medications Drops (Prescription or Over The Counter):	Taken For (Reason/Disease/Condition):

No Current Medications

REVIEW OF SYSTEMS

Height (ft):

inch:

Weight (lb):

Tetanus Shot Current?

Yes

Pregnant Or Nursing?

Yes

Due Date:

Kids - Birth/Dvpmt Hx:

General:

Ears, Nose, Throat:

Yes

Cardiovascular:

Yes

HTN?

Respiratory:

Yes

Genital, Kidney, Bladder:

Yes

Muscles, Bones, Joints:

Yes

Gastrointestinal:

Yes

Skin:

Yes

Neurological:

Yes

Psychiatric:

Yes

Endocrine:

Yes

Diabetes?

Type

Last A1C?

Blood/Lymph:

Yes

High Cholesterol?

Allergic/Immunologic:

Yes

Other Condition(s):

Yes

FAMILY MEDICAL HISTORY

Please Select "Other" To Type Multiple Answers Or Your Own Text.

Adopted: Family History Unknown

Blindness:

Cataracts:

Diabetes:

Eye Turn (Strabismus):

Lazy Eye (Amblyopia):

Glaucoma:

High Blood Pressure:

Macular Degeneration:

Other Disease:

SOCIAL HISTORY

Smoking Status

Discussed Cessation?

Do You Drink Alcohol?

EYE COMFORT QUESTIONNAIRE

1. during a typical day in the past month, how often did your eyes feel discomfort?

0 Never

1 Rarely

2 Sometimes

3 Frequently

4 Constantly

2. When your eyes felt discomfort, how intense was this feeling of discomfort at the end of the day, within two hours of going to bed?

0 Never Have It

1 Not At All Intense

5 Very Intense

3. During a typical day in the past month, how often did your eyes feel dry?

0 Never

1 Rarely

2 Sometimes

3 Frequently

4 Constantly

4. When your eyes felt dry, how intense was this feeling of dryness at the end of the day, within two hours of going to bed?

0 Never Have It

1 Not At All Intense

5 Very Intense

5. During a typical day in the past month, how often did your eyes look or feel excessively watery?

0 Never

1 Rarely

2 Sometimes

3 Frequently

4 Constantly

Policies, Consent, Submit Data

Please take time to read the following forms! Your signature here is equivalent to physically signing our office forms.

Preventative Eye Health Screenings

View Prevenative Eye Health Screenings

Patient Signature

Date

Notice Of Privacy Practices

View Notice Of Privacy Practices

Patient Signature

Date

Financial Policy

View Financial Policy

Patient Signature

Date