Patient Forms

Demographics

Patient Information

* Required

Title	First *	Last *	MI	Suffix	Nickname

Address 1: *
Address 2:
City: *		State/ZipCode *

Cell Phone: *		Preferred Contact Method:
Birthday *		Email
SSN		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Employer / School Name

Is this patient a minor?

If skipped, the patient is treated as an adult.

Parent / Guardian Information

Title	First *	Last *	MI	Suffix

Does the guardian live at the same address? *

Address *

City *	State *	ZipCode *

Home Phone:
Work Phone:

Medical Insurance

Medical insurance

Insurance Information

Do you have a medical plan?

Insurance Name: *

Insurance ID: *
Insurance Policy Group:

Are you the primary for this insurance? *

Primary on Account

Name: *	"place last name, then 1st name"
Relationship to Insured: *	Spouse Child Other
Sex:	Male Female

Address: *
City: *	State: Zip:
Phone Number:
Birthday: *
SSN:
Employer/School:

Secondary / supplemental medical insurance

Insurance Information

Insurance Name: *

Insurance ID: *
Insurance Policy Group:

Are you the primary for this insurance? *

Primary on Account

Name: *	"place last name, then 1st name"
Relationship to Insured: *	Spouse Child Other
Sex:	Male Female

Address: *
City: *	State: Zip:
Phone Number:
Birthday: *
SSN:
Employer/School:

Vision Insurance

Vision insurance

Insurance Information

Do you have a vision plan?

Insurance Name: *

Insurance ID: *
Insurance Policy Group:

Are you the primary for this insurance? *

Primary on Account

Name: *	"place last name, then 1st name"
Relationship to Insured: *	Spouse Child Other
Sex:	Male Female

Address: *
City: *	State: Zip:
Phone Number:
Birthday: *
SSN:
Employer/School:

Second vision plan

Insurance Information

Insurance Name: *

Insurance ID: *
Insurance Policy Group:

Are you the primary for this insurance? *

Primary on Account

Name: *	"place last name, then 1st name"
Relationship to Insured: *	Spouse Child Other
Sex:	Male Female

Address: *
City: *	State: Zip:
Phone Number:
Birthday: *
SSN:
Employer/School:

Medical History

Please complete all entries below, then push "submit" button on next tab to submit information to our office

Current / Past Eye Conditions

(check all that apply)

Vision Loss	Gritty Feeling	Infection	Diabetic Retinopathy
Blurry Vision	Itching	Stie	Glaucoma
Distorted Vision	Excess Watering	Flashes	Macular Degeneration
Dry Eyes	Light Sensitivity	Floaters	Retinal Detachment
Redness	Burning	Tired Eyes	Double Vision
Discharge	Eye Pain	Cataracts

Your History

Any other eye problems or conditions? (night-time blurriness or halos, dry or itchy eyes, computer eye strain, lumps or bumps, eye pain or discomfort)

Ocular History (Lasik, eye surgery, eye trauma, lazy eye, cataract surgery)

Allergies (seasonal, allergies to drugs, foods, medications)

Surgeries / Injuries (heart surgery, trauma to head, major accidents, etc)

Medications & Eye Drops (list any medications currently taking, including eye drops)

Social History

Alcohol use

Pregnant / Nursing

Smoking

Recreational drugs

Drives

Personal History

(select all that apply to you)

Gastrointestinal

Colitis

Crohns Dz

Ulcers

Constipation

Diarrhea

Neurological

Headaches

Seizures

Migraines

Multiple Sclerosis

Respiratory

Asthma

Bronchitis

Emphysema

Genitourinary

Bladder Problems

Kidney Problems

STD's

Constitutional

Fever

Weight loss/Gain

Fatigue

Trauma

Endocrine

Type I Diabetes

Type II Diabetes

Thyroid Dysfunction

Cardiovascular

Heart Dz

High Blood Pressure

High Cholesterol

Allergic/Immune

Drug Allergies

Seasonal Allergies

Arthritis

Skin

Eczema

Rosacea

Psoriasis

Ears/Nose/Throat

Allergies

Dry Mouth

Sinus Congestion

Musculoskeletal

Osteoarthritis

Fribromyalgia

Ankylosing Spond.

Lymph/Blood

Anemia

Bleeding Problems

Leukemia

Other conditions not specified

Family Medical History

(Check if any family members have or have had condition. Specify which family member in box open box next to condition)

Blindness	Cancer	Cataracts
Diabetes	Macular Degen	Heart Dz
Glaucoma	High BP	Retinal Detach
Kidney Dz	Crossed Eyes	Arthritis
Thyroid Dz	Lupus

Online Patient Form

Demographics

Medical Insurance

Vision Insurance

Medical History

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