Online Patient Form

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Patient Information

Title	First	Last	MI	Suffix	Nickname

Address:

City:	State:	Zip Code:

Home Phone:		Work Phone:
Other Phone:		Misc/Guardian
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 Insurance

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

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Chief Complaint/ History

How did you hear about us?

Referred By:

Race

Ethnicity

Preferred Language

Orientation to P/P/T:

Mood or affect:

Eye Medications:

Eye Over the Counter Medications:

Eye Vitamins:

CHIEF COMPLAINT

Secondary Issues:

Personal Ocular History

Eye Disease's or Conditions

Eye Injuries

Eye Surgeries - Ant Seg:

Eye Surgeries - Post Seg:

Personal Medical History

Pregnant or Nursing?

No Yes

Due Date

No current medications

CURRENT MEDICATIONS DROPS (OVER THE COUNTER MEDICATIONS)	TAKEN FOR (REASON/DISEASE/CONDITION)

MED ALLERGIES No known drug allergies

Family Ocular History

Adopted: FHx Unknown

Cataracts:

Glaucoma:

Macular Degen:

Retinal Detach:

Cancer:

Diabetes:

Heart Disease:

Other:

Inherited Disease:

Review Of Systems

GENERAL: Fever, weight loss, weight gain, fatigue?

EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat

CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease

RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD

KIDNEY, BLADDER: Kidney Stones, Frequent Urination, Pain

MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury

SKIN: growths, rashes, acne

NEUROLOGICAL: Headaches, migraines, seizures

PSYCHIATRIC: Depression, Anxiety, Insomnia

ENDORCRINE: Thyroid, Diabetes

Year Dx'd

Latest A1c

Controlled?

Tx:

BLOOD/LYMPH: Anemia, cholesterol, bleeding problems

ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus

GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

Primary Care Physcian:

Last Visit:

Reason For Visit:

Injuries, Surgeries, Hopitalizations:

Smoking Status:

Discussed Cessation?

Do you drink alcohol?