Online Patient Forms

Patient Information

Upload Driver Lisc [front]:

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Upload Driver Lisc [back]:

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First Name

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Last Name

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Nickname

Birth Sex

Male Female

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Address

Apt/Suite #

City

State

Zip Code

Cell Phone

*This field is required

Home Phone

Preferred Contact Method

Birthday

SSN

Occupation

Employment Status

Employed Fulltime Student Parttime Student

Employer/School Name

Marital Status

Misc/Guardian

Who may we thank for referring you to our office?

Billing Information

Is The Billing Address Different?

Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

Apt/Suite:

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!

General Medical History

Primary physician's name and phone

When was your last physical exam?

Check the box for any conditions that apply

	You	Mom	Dad	Sib	Describe (type, when were you diagnosed, etc)
Hypertension
Thyroid
Cardiovascular
Cancer
Diabetes

If YOU are diabetic, when were you diagnosed?

Last A1C level?

Are you Pregnant or Nursing?

List ALL major injuries or surgeries you have had and approx dates:

List any other medical conditions you have had, including non-drug allergies:

List all Rx and over-the-counter medications you currently take:

List any vitamins or supplements you currently take:

List any drug allergies you have:

Smoking Status

Alcohol Use

Do you live alone?

Review Of Systems

Please list any problems you are currently having anywhere, from head to toe

General

Skin

Ear/Nose/Throat

Respiratory

Muscles, Bones, Joints

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genital, Kidney, Bladder

Gastrointestinal

Cardiovascular

Ocular History

Who was your previous eye doctor?

Last Eye Exam

Check the box for any conditions that apply

	You	Mom	Dad	Sib	Describe (type, when were you diagnosed, etc)
Glaucoma
Macular Degeneration
Retinal problems
Cataracts
Lazy Eye/Eye Turn

List any major eye injuries, infections or surgeries and approx dates:

List any other significant eye problems you have had:

List all Rx and over-the-counter eye medications you currently use:

List any vision complaints you are currently having such as:

How many hours/day do you typically spend using a computer or other digital devices?

If you are having complaints with computer work, how far is the monitor from your eyes?

How many hours/day do you typically spend reading books, magazines, etc?

Do you have any difficulty seeing or driving at night?

What are your hobbies/sports activities?

Do you have sunglasses?

Do you have back-up glasses?

Are you interested in contacts?

Contact Lens Wearers only:

What disinfecting solution do you use?

How long do you usually wear your lenses?

How often do you replace your lenses?

How old is your current pair of contacts?

Patient Signatures

Please review the following agreement. Sign below to acknowledge and attach your signature to the final PDF.

Please ADD the above numbers together.