Online Patient Form
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After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!
Patient Information
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip Code:
Home Phone:
Work Phone:
Other Phone:
Alerts:
Cell Phone:
Preferred Contact Method:
Home Phone
Work Phone
Cell Phone
Other Phone
Text Message
Email
SSN
Email
Birthday
Occupation
Sex
Male
Female
Employment Status
Employed
Full-Time Student
Part-Time Student
Marital Status
Annulled
Divorced
Domestic partner
Interlocutory
Legally Separated
Married
Never Married
Polygamous
Widowed
Employer / School Name
Misc/Guardian
Who may we thank for referring you to our office?
Billing Information
Is The Billing Address the Same?
Yes
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip Code:
Home Phone:
Work Phone:
Insurance Information
Insurance Name:
None
Block Vision
Davis Vision
EyeMed
March Vision
Spectera
UFT
Vision Service Plan
Insurance Plan:
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
Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!
Do you have any of the following symptoms?
None
Itching
Double Vision
Burning
Tearing
Loss of Vision
Floaters
Flashes
Eye Strain
Headache
Eye Pain
Reason for Visit:
blurred vision
distance vision blurry
near vision blurry
vision blurry distance and near
wants to be fitted for contacts
needs new glasses
red eye
pain in eye
loss of vision
injury to eye
itching
burning
stinging
dry eyes
Diabetic eye exam
annual doctor directed diabetic eye exam
broken glasses
failed screening at school
failed screening at pediatrician's office
Physician directed eye exam
Complete eye exam to rule out problems
Other
Secondary Reasons:
Ocular History:
Itching
Burning, Stinging
Amblyopia
Eye Injuries
Eye Surgery
Flashes Of Light
Floaters
Strabismus
Cataracts
Glaucoma
Retinal Disorders
None
Other
Eye Meds:
None
Cromolyn NA 4%
Visine
Patanol
Xalatan
Travatan
rewetting drops
Elestat
Vigamox
Alphagan
Refresh
Theratears
Genteal
Pred Forte
Lotemax
Alrex
Systane
Blink
Other
Last Eye Exam:
1 year
2 years
3 years
Other
By Doctor:
Boyle
Cass
Doesn't Remember
Never
DeRouen
Maynard
Blount
Hyde
Doucet
Singla
Abbas
Harmon
Levacy
Diaz
Lehman
Chuckweike
Fracht
Conroy
Lens Crafters
EyeMart
EyeMasters
Pearl
Rising
Yu
Johnson
Broussard
Other
Primary Vision Correction:
None
Glasses-Full Time
Glasses-Readers Only
Contacts - Soft
RGPs
PMMA
OTC readers
Other
Back up glasses?
Yes
No
Other
Want new glasses?
Yes
No
Other
Type of contacts worn in past:
None
Disposable
Conventional
Colored
RGP
PMMA
Cobalt Study Lens
Soft
Other
Wear Time:
>2 hours today
All day
Occ. Overnight
Extended
8 hours
10 hours
12 hours
Overnight
Other
Cleaner:
Optifree
Clear Care
Boston
Renu
Other
Disposal:
2 weeks
monthly
daily
weekly
yearly
Other
Family Eye History
Macular Degeneration:
No
Parents
Siblings
Grandparent
Other
Glaucoma:
No
Parents
Sibling
Grandparent
Other
Retinal Detachment:
No
Parents
Siblings
Grandparent
Other
Cataracts:
No
Parents
Siblings
Grandparent
Other
Crossed/Lazy:
No
Parents
Siblings
Grandparent
Other
Medical History
Primary Care Physician:
Doesn't Have One
Doesn't Remember
None
Wilson
Chin-Ha
Other
Last Visit:
1 week
1 month
3 months
6 months
1 year
2 years
Other
Reason For Visit:
Check up
Annual
Other
Over The Counter Meds:
None
Asprin
Acetomenophin
Ibuprofen
Other
Vitamins:
None
A
E
C
Zinc
Xanten
Lutein
Other
Allergies:
No Known Drug Allergies
Injuries, Surgeries, Hospitalizations:
Pregnant Or Nursing:
No
Yes
Unsure
Other
Family Medical History
None
Adopted
Diabetes
HBP
Cancer
Cardiovascular Disease
Arthritis
Kidney Disease
Lupus
Thyroid
Other
Review of Systems
General:
None
Fatigue
Fever
Loss of Appetite
Weight Gain
Weight Loss
Developmental Disorders
Other
Ear/Nose/Throat:
None
Neck Problems
Sinus Problems
Sore Throat (Recent)
Headache
Morning Headaches
Migraine Headache
Cluster Headache
Hearing Loss
Tinnitus
Congestion
Dry throat / mouth
Sleep Apnea
Other
Skin:
None
Acne
Lupus
Dermatitis
Eczema
Psoriasis
Rosacea
Skin Cancer
Itching
Other
Cardiovascular:
None
Congestive Heart Disease
Cardiovascular Disease
High Cholesterol
Hypertension
Arrhythmia
Heart Murmur
Heart Palpitation
Chest Pain
Arteriosclerosis
Coagulation Disorder
Mitral Valve Prolapse
Low Blood Pressure
Other
Respiratory:
None
Asthma
Cancer: lung
Sleep Apnea
Sarcoidosis
COPD
Emphysema
Pneumonia
Bronchitis
Shortness of breath
Wheezing
Other
Musculoskeletal:
None
Arthritis
Osteoporosis
Fibromyalgia
Osteoarthritis
Muscular Dystrophy
Lupus
Decreased range of motion
Muscle cramps
Pain/tenderness
Stiffness
Swelling
Weakness
Other
Psychiatric:
None
Attention Deficit Disorder
Anxiety
Brain Damage (trauma)
Panic Attacks
Alzheimer's Disease
Bi-polar
Depression
Insomnia
Obsessive/Compulsive
Paranoia
Suicidal
Violence
Other
Gastrointestinal:
None
Acid Reflux
Crohn's disease
Gastric reflux (GERD)
IBS
Ulcer
Gall bladder problems
Jaundice
Hepatitis
Sarcoidosis
Cancer: colon
Cancer: Liver
Other
Endocrine:
None
Crohn's disease
Diabetes Type 1
Diabetes Type 2
Diabetes Suspect
Hypothyroid
Hyperthyroid
Gout
Hormone Replacement Therapy
Other
Blood/Lymph:
None
Anemia
Hx of Significant Blood Loss
Hematologic Disorder
Sickle Cell Disorder
Breast Carcinoma
Lymph Node Disease
Temporal Arthritis
Cuts slow to clot
Easy bruising
Other
Neurological:
None
Multiple Sclerosis
Seizure Disorder
Parkinson's Disease
Brain Tumor
Bells Palsy
Dyslexia
Headache
Balance problems
Vertigo
Tremors
Changes in senses
Dementia
Memory problems
Muscle weakness
Numbness, paralysis
Personality changes
Speech problems
Other
Genitourinary:
None
Amenorrhea
Menopause
Impotence
Jaundice
Uterine Cancer
Prostate Cancer
Kidney Stones
Pregnant
Nursing
Syphilis
Prostate Problems
Bladder Infections
STD- herpetic
STD- chlamydia
Other
Immune:
None
Seasonal allergies
Environmental allergies
Food allergies
Drug allergies (please specify)
Sjogren's syndrome
AIDS
Herpes Simplex
HIV Simplex
Mononucleosis
Tuberculosis
Cytomegalovirus Infection
Herpes Zoster
Lyme Disease
Sarcoidosis
Syphilis
Hives
Itching
Mild allergy symptoms
Severe allergy symptoms
Swelling
Other
Social History
Hobbies:
Astronomy
Art
Baseball
Boating
Basketball
Cooking
Crafts
Dancing
Diving
Football
Fishing
Golf
Gardening
Horseback Riding
Hunting
Models
Needlepoint
None
Painting
Photography
Piano
Reading
Running
Roller Blading
Softball
Sewing
Skiing
Soccer
Swimming
Tennis
Video Games
Woodworking
Other
Smoking Status:
Never Smoker
Current every day smoker
Current some day smoker
Former smoker
Smoker, current status unknown
Unknown if ever smoked
Other
Type:
None
Cigarettes
Chewing Tobacco
Other
How Long:
Alcohol:
No
Yes
Occasionally
Socially
Other
Type:
None
Beer
Wine
Hard Liquor
Other
How Long:
Illegal Drugs:
No
Yes
Other
Type:
How Long:
Race:
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other
Ethnicity:
Non Hispanic or Latino
Hispanic or Latino
Other
Preferred Language:
English
French
German
Spanish
Other
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