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 Employment Status
Marital Status Employer / School Name
Misc/Guardian

Race: Preferred Language:

Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Primary

Insurance Information
Insurance Name:
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:

Secondary

Insurance Information
Insurance Name:
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:

Tertiary

Insurance Information
Insurance Name:
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

Eye History

Reason for Visit:
Secondary Reasons:

Do you have a history of the following?:

Ocular Allergies: Flashes/Floaters: Dry Eyes:
Eye Infections: Eye Surgery: Eye Injury: Double Vision:

Do you or anyone in your family have a history of the following?:

Glaucoma: Retinal Detach:
Cataracts: Turn/Lazy Eye:
Mac Degen:

Other:

Medical History

Medications:
Primary Care Physician:

Do you regularly use: Alcohol Tobacco Drugs

Do you currently have any of the following?:

High Blood Pressure: Diabetes:
High Cholesterol: Cancer:
Thyroid Condition: Arthritis:
Allergies/Sinus: Asthma:
Cardio Condition: Migraines:
Immune Condition: Pregnant/Nursing:

Other:

Does your family have a history of the following?:

Glaucoma: Retinal Disease:
Cataracts: Mac Degeneration:
Diabetes: Cardio Condition:
Cancer: High Blood Pressure:

Other:

Review of Systems

General: (ex. Fever, Weight loss, Weight gain, Fatigue)
Ear/Nose/Throat: (ex. Allergies, Sinus, Cough, Dry Mouth / Throat)
Cardiovascular: (ex. High BP, Heart Surgery, Vascular Disease)
Respiratory: (ex. Asthma, Bronchitis, Emphysema, COPD)
Genitourinary: (ex. Kidney Stones, Frequent Urination, Impotence)
Musculoskeletal: (ex. Athritis, Joint Pains, Head or Neck Injury)
Skin: (ex. Growths, Rashes, Acne)
Neurological: (ex. Headaches, Migraines, Seizures)
Psychiatric: (ex. Depression, Anxiety, Insomnia)
Endocrine: (ex. Thyroid, Diabetes)
Blood/Lymph: (ex. Anemia, Cholesterol, Bleeding Problems)
Allergy/Immune: (ex. Seasonal Allergies, AIDS, Lupus)
Gastrointestinal: (ex. Diarrhea, Constipation, Ulcer, Reflux)

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