Vision Eye Max - Online Patient Form

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Demographics


Patient Information
TitleLastFirstMISuffixNickname
Address:
City: State: ZipCode:
* Home Phone: Email
* Cell Phone: Preferred Contact:
Work Phone:Recieve Texts?:
Sex Occupation
Birthday (mm/dd/yyyy) Employment Status
SSN (###-##-####) Employer / School
Marital StatusMisc/Guardian


Billing Information
TitleLastFirstMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:


Medical Insurance


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


Vision Insurance


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


Medical History


Reason for visit:
How did you hear about us?

Ocular History
Ocular Diseases/Injuries:
Ocular Surgery:
Eye Drops/Meds:
Last Eye Exam: Last Eye Doctor/Office:
Primary Vision Correction: Want new glasses?
Type of CLs worn in past: CL Solutions Used:
Average CL Wear Time: CL Replace/Toss schedule:

Medical History
Last Health Exam: Primary Care Physician:
Medications: No current medications
Allergies: No known drug allergies
Vitamins/Supplements: Are you pregnant or nursing?

Review of Systems
General (fatigue, fever, weight loss/gain, etc.)
Ear, nose, and throat (chronic cough, dry mouth, runny nose, congestion, etc.)
Cardiovascular (heart disease, high cholesterol, hypertension, vascular disease, etc.)
Respiratory (asthma, brochitis, emphysema, etc.)
Genital, kidney, and bladder (kidney problems, impotence, painful urination, etc.)
Muscles, bones, and joints (arthritis, pain, tenderness, etc.)
Gastrointestinal (Crohn's Disease, irritable bowel syndrome, GERD, acid reflux, etc.)
Skin (eczema, itching, rosacea, psoriasis, etc.)
Neurological (dementia, paralysis, multiple sclerosis, seizures, etc.)
Psychiatric (ADHD, anxiety, depression, paranoia, etc)
Endocrine (type 1 diabetes, type 2 diabetes, hyperthyroid, hypothyroid, etc.)
Blood/lymph (anemia, bleeding disorders, shortness of breath, etc.)
Allergic/immunologic (hives, seasonal, etc.)
Others

Family History
Ocular HistoryMedical History
Glaucoma: Diabetes:
Cataracts: Hypertension:
Macular Degeneration: High Cholesterol:
Retinal Detachment: Thyroid:
Crossed / Lazy Eye: Cardiovascular:
Blindness: Cancer:
Additional Info:Additional Info:

Social History
Hobbies:
Smoking Status: Type: Years:
Alcohol: Type: Years:
Race: Ethnicity: Preferred Language:


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