Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev. Fr. Miss

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
Misc/Guardian

Is the Billing Address Different?

Billing Information

Address Same As Above

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Fr. Miss

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:

Medical History

Please choose from the menu choices or select "Other" for multiple options and type in your own text. Thank you!

Patient, Family, and Social Histories

Check If Healthy, All Normal, No Medications

List Major Health Issues, Surgeries

Reason for Referral
Primary Care Physician or Referring Physician

Current Medications:

Current EYE Medications/Drops
OTC Eye Drops/Meds

Drug Allergies:

No Known Drug Allergies Codeine Penicillin Sulfa Aspirin Compazine Erythromyacin Ceclor Other

Pregnant Or Nursing:

No Yes Unsure Other

STD HISTORY:	None Clamydia Gonococcol HIV Herpes Simplex AIDS Other
POSITIVE HIV BLOOD TEST:
POSITIVE HEP A/B/C:
CANCER (TYPE):

Contact Lens History

Do you currently wear contact lenses?

Yes

In the past

No, but I'm interested

No

If so, what brand are you currently wearing?

Full time wear

Part time wear

I wear my contacts overnight

I take my contacts out each night

Past and Current Ocular History

Last Eye Exam:

1 year 2 years 3 years 4 years 5 years > 5 years First Other

Doctor:

Doesn't Remember Never Deemer Smith Jarnagin Berger McMahon Parot Other

Check If None Apply

Cataracts

Glaucoma

Loss of Vision

Itchy Eyes

Dry Eyes

Eye injury

Corneal Ulcer/Keratitis

Refractive Surgery(LASIK/PRK/RK)

Cataract Surgery

Double vision

Flashes

Floaters

Lazy Eye

Iritis/Uveitis

Retinal Detachment, Hole or Tear

Macular Degeneration(DRY or WET)

Keratoconus/Corneal Degeneration

Eye Muscle Surgery

ANY Other Eye condition

Red Eyes

Tired Eyes

Headaches

Glare/Halos

Eye Discomfort/Irritation

Eye Pain/Sore Eyes

Exessive overflow tearing

Soft Contact Lens Wearer

Rigid Gas Perm Lens Wearer

Notes:

Family Ocular History

Check if All No

Glaucoma

Corneal Transplant

Keratoconus/Corneal Degeneration

Cataracts

Macular Degeneration

Blindness

Diabetic Retinopathy

Retinal Detachment

Strabismus/Crossed eyes

Amblyopia

Any other Ocular Condition/Disease

FAMILY MEDICAL HISTORY: Diabetes, HBP, Heart Dz, Cancer, Athritis, Lupus, Kidney, Thyroid, Other

None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid Other

Are you interested in learning about the latest technology in contact lenses?	Yes	No
Are you interested in LASIK or other refractive surgery options?	Yes	No
Are you interested in learning about the latest interocular lens implants for vision correction?	Yes	No
I would like to have digital retinal images taken today.	Yes	No

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