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/GuardianDrivers License #



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:
Sex:
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:
Sex:
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:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Vision

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:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

Medical History
Primary Vision Correction:
Hobbies:
Ever worn Contact Lenses?
Interested In Contact Lenses?
Type of contacts worn in past:
Back up specs for contacts?
Sunspecs?
Interested in Laser Vision Correction?
Eye Meds:
PCP:
Last Eye Dr:
Allergies: NONE
Medications: NONE
Major Injuries / Hospitalizations:

Race: Ethnicity:
Height Ft.: Inch: Weight: Preferred Language:
Smoking Status: Do you drink alcohol? If so, how much and how often:


EYES: Do you currently have any problems with?

Loss of Vision
Blurred Vision
Distorted Vision / Halos
Loss of Side Vision
Double Vision
Dryness
Mucous Discharge
Redness
Sandy or Gritty Feeling
Itching
Burning
Foreign Body Sensation
Excessive Tearing / Watering
Glare / Light Sensitivity
Eye Pain or Soreness
Chronic Infection of Eye or Lid
Sties or Chalazion
Flashes / Floaters in Vision
Tired Eyes
Other


Patient Medical Conditions:

Constitutional:
Integumentary (Skin):
Neurological:
Endocrine:
Ears, Nose, Mouth, Throat:
Respiratory:
Vascular / Cardio:
Gastrointestinal:
Genitourinary:
Bones / Joints / Muscles
Lymphatic / Hematologic:
Allergic / Immunologic:
Psychiatric:


Please note any FAMILY history for the following:


DISEASE/CONDITION Relationship to you
None
Mom Dad Sister Brother Mom's Mom Mom's Dad Dad's Mom Dad's Dad
Blindness
Cataract
Crossed Eye
Glaucoma
Macular Degeneration
Retinal Detachment/Disease
High Blood Pressure
Arthritis
Cancer
Diabetes
Lupus
Kidney Disease
Thyroid Disease
Heart Disease

Other

Dry Eye History

Symptoms

Do you have any problems with dryness, grittiness or scratchiness?

Currently?
Past 72 hrs?
Past 3 mos?
How often do you experience this?
How Severe is it?

Do you have any problems with soreness or irritation?

Currently?
Past 72 hrs?
Past 3 mos?
How often do you experience this?
How Severe is it?

Do you have any problems with burning or watering?

Currently?
Past 72 hrs?
Past 3 mos?
How often do you experience this?
How Severe is it?

Do you have any problems with eye fatigue?

Currently?
Past 72 hrs?
Past 3 mos?
How often do you experience this?
How Severe is it?

Do you use drops for lubrication?
If yes, how often?

Final