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 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:

Vision Insurance

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:

Primary Medical

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 Medical

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

Medical History
Reason for Visit:   Secondary Reasons:
  
Last Eye Exam: By Dr:

Have you had any eye injuries or surgeries?:
Do you have a history of these eye conditions?:

Do you use any eye drops?:
Are you interested in contacts?:

Do you have backup glasses?: Do you use sunglasses?:

Do you or your family members have these eye conditions?

    You   Mom   Dad   Sibling   None   Describe
Glaucoma:                           
Macular Degen:                           
Retinal Issues:                           
Cataracts:                           
Lazy/Cross Eye:                           


Do you or your family members have these medical conditions?

Unknown family history

    You   Mom   Dad   Sibling   None   Describe
Diabetes:                            Year Diagnosed: A1c:
High BP:                           
Thyroid:                           
Heart:                           
Cancer:                           


Pregnant/Nursing?: Last Physical Exam: Primary Care Physician:

Height: ft. in.    Weight: lbs.

Do you take any of these medications? No current medications
Are you allergic to any medications? No known drug allergies
Do you take any vitamins/supplements?:

Have you had any major injuries or surgeries?:
Do you have a history of any of these conditions?:

Review of Systems
General: Ear/Nose/Throat:
Endocrine: Cardiovascular:
Respiratory: Gastrointestinal
Immune: Musculoskeletal:
Skin: Blood/Lymph:
Psychiatric: Genitourinary:
Neurological:
Social History
Hobbies: Do you Live Alone?: Referred By:

Smoking Status: Alcohol Use:

Race: Ethnicity: Preferred Language:

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