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
Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Vision Insurance

Primary 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:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:
Secondary 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:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical Insurance

Primary Medical 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:
Secondary Medical 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

Medical History

Personal History

How Old is Current Prescription?: Ever Worn Contact Lenses? Type of CLs worn in past:
Last Eye Exam Date with Doctor: Last Medical Exam Date with Doctor:

Hobbies:

Review of Systems

Smoking Status: Do You Drink Alcohol?:
Preferred Language: Ethnicity:

Exposure to Infectious Disease?

Do you currently have any of these problems?

General
Fever, Weight Loss/Gain:
(Skin) Shingles:
Endocrine
Thyroid/Other Glands:
Immune Problems:
Blood/Lymph
Anemia:
Bleeding Problems:
Neurological
Headache:
Migraine:
Seizures:
Multiple Sclerosis

Eyes
Blurred Vision:
Burning:
Gradual Vision Change:
Sudden Vision Change:
Chronic Infection/Stye:
Distorted Vision:
Dryness:
Double Vision:
Excess Tearing/Watering:
Eye Fatigue:
Eye Pain/Soreness:
Flashes:
Floaters:
Foreign Body Sensation:
Itching:
Loss of Vision:
Loss of Side Vision:
Light Sensitivity/Glare:
Mucous Discharge:
Redness:
Sandy/Gritty Feeling:

Gastrointestinal
Diarrhea:
Constipation:
Kidney/Bladder Problems:
Ear/Nose/Throat
Allergies/Hay Fever:
Chronic Cough:
Dry Throat/Mouth:
Post-Nasal Drip:
Runny Nose:
Sinus Congestion:

Respiratory
Asthma:
Chronic Bronchitis:
Emphysema:

Cardiovascular
Aneurysm:
Diabetes:
COPD:
Cong. Heart Failure:
Heart Attack:
Heart Pain:
Hypertension:
Stroke

Bones/Joints/Muscles
Osteoarthritis:
Joint Pain:
Muscle Pain:
Rheumatoid Arthritis:
Eye History
Amblyopia
Diabetic Eye Disease:
Cataracts:
Crossed Eye:
Glaucoma:
Macular Degeneration:
Retinal Detachment:
Retinal Disease:
Thyroid Eye Disease:
Other:

Family History
Amblyopia:
Blindness:
Cataract:
Crossed Eye:
Glaucoma:
Macular Degen:
Macular Detach:
Retinal Disease:
Arthritis:
Cancer:
Diabetes:
Heart Disease:
High Blood Pressure:
Kidney Disease:
Lupus:
Thyroid Disease:
Other:

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