Mt Hood Eye Care Online Patient Form
Demographics
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
City:
State/ZipCode
TX
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
UT
VT
VI
VA
WA
WV
WI
WY
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
Primary Doctor
No Doctor Assigned
Dr. Turin, Tony
Misc/Guardian
Billing Information
Is The Billing Address the Same?
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Address
City
State
ZipCode
TX
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
UT
VT
VI
VA
WA
WV
WI
WY
Home Phone:
Work Phone:
Primary
Insurance Information
Insurance Name:
None
Aetna
Cigna
Claims Central
Dr. Sayson
EBMS
Eyemed Vision Plan
First Choice Health
Healthcare Management Administrators
Healthnet
Lifewise
Medicare
Meritain Health Insurance
MODA
No Insurance
Pacificsource
Providence
Regence
Risk Management
Risk Management RE
Tricare
UMR
VSP
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:
None
Aetna
Cigna
Claims Central
Dr. Sayson
EBMS
Eyemed Vision Plan
First Choice Health
Healthcare Management Administrators
Healthnet
Lifewise
Medicare
Meritain Health Insurance
MODA
No Insurance
Pacificsource
Providence
Regence
Risk Management
Risk Management RE
Tricare
UMR
VSP
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
VISUAL HISTORY:
Breifly describe the main reason for having an examination today:
Modifying Factors
cold compress helps
warm compress helps
correction improves vision
oral pain reliever helps
Timing
improving
worsening
same
Severity
mild
moderate
severe
debilitating
Duration
1 day
2 days
3 days
1 week
1 month
3-6 months
> 1 year
Location
OD
OS
OU
Chief complaint
blurred vision distance
blurred vision near
blurred vision distance/near
headache
pain
watery
itch
redness
Do you have any other symptoms related to this?
none
dizzy
headache
loss of vision
blurred vision
Context/Cause:
computer
outside
Other eye issues or problems
I currently wear glasses:
Part-time
Full-time If part-time, how often/when?
Occasionally
Driving
1-2 times per week
Half time
Sports
Weekends
Social activities
I currently wear contacts:
Part-time
Full-time If part-time, how often/when?
Occasionally
Driving
1-2 times per week
Half time
Sports
Weekends
Social activities
Contact Lens Wearers: Are your lenses comfortable?
Yes
No Current Brand:
Acuvue 1-day
Acuvue 1-day Moist
Acuvue 1-day Trueye
Acuvue 2
Acuvue Oasys
Acuvue Oasys for Astigmatism
Acuvue Oasys for Presbyopia
Acuvue Advance
Acuvue Advance for Astigmatism
Air Optix
Air Optix Night & Day
Air Optix Astigmatism
Air Optix Multifocal
Avaira
Biomedic Toric
Biomedic XC
Biofinity
Biofinity Toric
Biofinity Multifocal
Clearsight 1 day
Clearsight 1 day Toric
Focus Dailies Standard
Focus Dailies AC plus
Focus Dailies Toric
Frequency 55
Frequency 55 Toric
Frequency 55 Aspheric
Freshlook colorblends
Proclear
Proclear 1 day
Proclear EP
Proclear Multifocal
Purevision
Purevision 2
Purevision 2 Toric
Purevision Multifocal
Soflens 38
Soflens Toric
Soflens Daily Disposable
Soflens Multifocal
Vertex Toric
Boston EO
Boston ES
Boston XO
Fluoroperm 60
Menicon Z Thin
RGP - unknown material
What solution do you use?
None
Optifree Replenish
Optifree Pure Moist
Optifree Express
Renu
Biotrue
Clear Care
Kirkland Signature
Revitalens
Generic store brand
Boston Advance
Boston original
Optimum
B & L Gas Perm
Unique Ph
What is your replacement schedule?
Daily
Weekly
Every 2 weeks
Monthly
If they feel bad
Quarterly
Yearly
How old is your current pair?
new
1-2 weeks
2-4 weeks
very old
Please list eyedrops you use:
none
Blink
Genteal
Optive
Refresh Plus
Similisan
Systane
Generic artificial tears
Murine
Visine
Lumigan
Travatan
Xalatan
Timoptic
How often used?:
daily
occasionally
rarely
Do you have a history of any of the following?
YES NO
YES NO
YES NO
Blindness
Glaucoma
Eye Turn
Retinal Detachment
Lazy Eye
Keratoconus
Macular Degeneration
Cataracts
Are you currently experiencing any of the following?
YES NO
YES NO
YES NO
Frequent Styes
Floaters
Double Vision
Eyes itch
Eyes burn
Eyes tear
Flashing lights
Headache
Blurred Vision
How many hours a day do you use a computer?
<2 hours
2 - 4 hours
5 - 8 hours
9 - 12 hours
12+ hours
Describe any visual symptoms from computer use:
none
Eye strain
Blurred vision
Headache
Dry eyes
Watery
Itch
Burn
Double vision
Can we pray for you?
Yes
Yes, in office
No thank you
MEDICAL HISTORY
Physician's Name:
Last Visit Date:
List all medications you are currently taking (including vitamins):
Medical Allergies:
Are you pregnant or nursing?
No
Yes
If yes, what is the due/birth date?
Do you have, or ever had, any CHRONIC problems in the following areas?
YES NO
YES NO
YES NO
Thyroid problems
Arthritis
Diabetes
Multiple Sclerosis
Migraines
Stroke
High blood pressure
Asthma
Anemia
Allergies/Hay fever
Emphysema
Cancer
Notes/Comments:
FAMILY HISTORY
(Family history is unknown/adopted)
Any history of the following in any family members (parents, grandparents, siblings, children)?
YES
NO
Relationship
YES
NO
Relationship
Poor Vision
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Cancer
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Blindness
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Diabetes
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Eye Turn
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
High Blood Pressure
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Lazy Eye
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Stroke
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Glaucoma
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Thyroid Disease
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Cataracts
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Macular Degeneration
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Other Inherited Disease
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
If yes, what disease?
SOCIAL HISTORY (confidential)
How often do you smoke/use tobacco products?
Never
Occasionally
Daily
How often do you consume alcohol:
Never
Occasionally
Daily
Do you have?
Hepatitis
HIV
STDs
Occupation:
Employer:
REFERRALS
Who referred you to our office?
If not referred, how did you hear about Mt Hood Eye Care?
Family member
Insurance list
Coworker
Friend
Primary Care Doctor
Internet
Drove by
Date:
Submit Data
After Completing All Forms Submit Data on Final Tab