Online Patient Form

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Patient Information
City: State/ZipCode
Home Phone: Work Phone:
Other Phone:
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?

Home Phone:
Work Phone:

Medical History

Chief Complaint
Reason for Visit:
Location: Severity: Quality: Duration:
Timing: Context: Modifying: Associated:
Secondary Reasons:
Review of Ocular System
Ocular History: Eye Meds:
Last Eye Exam: By Doctor:

Primary Vision Correction:
Back up glasses? Want new glasses?

Type of contacts worn in past:
Cleaner: Disposal: Wear Time:
Days per week worn: Hours worn comfortably:

Family Eye History

Does your family have a history of any of these eye conditions? Unknown family history

Macular Degen: Glaucoma:
Retinal Detach: Cataracts:
Review of Systems
General: Gastrointestinal:
Respiratory: Ear/Nose/Throat:
Immune: Cardiovascular:
Skin: Muscles/Bones:
Psychiatric: Blood/Lymph:
Endocrine: Genitourinary:
Medical History
Vitamins: Over The Counter Meds:
Primary Care Physician: Last Visit: Reason:
Pregnant Or Nursing Recent Tetanus Shot
Injuries, Surgeries, Hospitalization:
Family Medical History

Does your family have a history of these medical conditions?

Blood Pressure: Describe:
Diabetes: Type:
High Cholesterol: Describe:
Thyroid Issues: Describe:
Heart Problems: Describe:
Cancer: Describe:
Social History
Hobbies STD's:

Smoking Status: Type: How Long:
Alcohol Use: Type: How Long:
Illegal Drug Use: Type: How Long:

Race: Ethnicity: Preferred Language:

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