Online Patient Form

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Demographics


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
Primary Doctor Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Primary

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Tertiary

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

Eye History
Reason for Visit:
Location: Severity: Quality: Duration:
Timing: Context: Modifying: Associated:
Secondary Reasons:

Ocular History
Eye Meds: Last Eye Exam: By Doctor:
Primary Vision Correction: Back up glasses? Want new glasses?

Family Ocular History

Family History Unknown
Macular Degen: Glaucoma:
Retinal Detach: Cataracts:
Crossed/Lazy Eye:

Contact Lens History

1st time contact wearer
Type of contacts worn: Extended wear: Replacement:
Solutions Used: Current Pair:
Medical History
Injuries/Surgeries: C-Section Hysterectomy Gallbladder Appendix Tonsils/Adenoids
Pregnant Or Nursing:
Primary Care Physician: Last Visit: Reason For Last Visit:
Over The Counter Meds: Vitamins: Do you take medication for:

Do you have an allergy to:
Penicillin Sulfa Morphine
Codeine Amoxicillin Bactrim No Known Drug Allergies

Family Medical History

Does your family have a history of the following conditions?
Diabetes: High Blood Pressure: Thyroid Disease: Other:

Social History

Occupation: Hobbies: STD:

Smoking Status: Type: How Long:
Alcohol Use: Type: How Long:
Illegal Drugs: Type: How Long:
Race: Ethnicity: Preferred Language:
Review of Systems
General: (Fever, Weight Loss, Weight Gain, Fatigue)
Ear/Nose/Throat: (Allergies, Sinus, Cough, Dry Mouth/Throat)
Cardiovascular: (High BP, Heart Surgery, Vascular Disease)
Respiratory: (Asthma, Bronchitis, Emphysema, COPD)
Genitourinary: (Kidney Stones, Frequent Urination, Impotence)
Muscles/Bones: (Arthritis, Joint Pains, Head or Neck Injury)
Skin: (Growths, Rashes, Acne)
Neurological: (Headaches, Migraines, Seizures)
Psychiatric: (Depression, Anxiety, Insomnia)
Endocrine: (Thyroid, Diabetes)
Blood/Lymph: (Anemia, Cholesterol, Bleeding Problems)
Immune: (Seasonal Allergies, Rheumatoid, AIDS, Lupus)
Gastrointestinal: (Diarrhea, Constipation, Ulcer, Reflux)

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