Mt Hood Eye Care Online Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Primary Doctor Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Primary

Insurance Information
Insurance Name:
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 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 Timing Severity
Duration Location Chief complaint
Do you have any other symptoms related to this? Context/Cause:
Other eye issues or problems

I currently wear glasses: Part-time Full-time If part-time, how often/when?
I currently wear contacts:Part-time Full-time If part-time, how often/when?
Contact Lens Wearers: Are your lenses comfortable?YesNo Current Brand:
What solution do you use? What is your replacement schedule?
How old is your current pair? Please list eyedrops you use:
How often used?:

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?
Describe any visual symptoms from computer use:
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                Cancer                               
            Blindness                    Diabetes                          
            Eye Turn                      High Blood Pressure     
            Lazy Eye                       Stroke                               
            Glaucoma                   Thyroid Disease              
            Cataracts                    Macular Degeneration    
            Other Inherited Disease         If yes, what disease?
SOCIAL HISTORY (confidential)
How often do you smoke/use tobacco products?
How often do you consume alcohol:
Do you have?HepatitisHIVSTDs
Occupation:Employer:
REFERRALS
Who referred you to our office?
If not referred, how did you hear about Mt Hood Eye Care?
Date:

Submit Data

After Completing All Forms Submit Data on Final Tab