Online Patient Form

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Demographics


Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Cell Phone:
Preferred Contact Method: Email:
Birthday: Occupation:
Sex: Male Female Employment Status: Employed Full-Time Student
Part-Time Student
Marital Status: Employer / School Name
Primary Eye Doctor: Misc/Guardian
Primary Care Doctor
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Medical 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:

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:

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:

Secondary Vision

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:

Chief Complaints


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Chief Complaints
Reason for Visit:
Secondary Complaints:
Ocular History:
History of eye disease, surgery, or eye trauma

Distance Vision:       Last Eye Exam:
Near Vision       Referral By:

Primary Vision Correction:

Headaches: Eye Pain: Double Vision: Tearing:
Dryness: Flashes: Spots: Itching:
Burning: Redness: Eye Turn:


Ocular Family History

Glaucoma: Macular Degeneration: Retina Disorders:
Lazy Eye: Eye Turn: Other:

Eye Meds:

Contact Lens Wearers: Are your contact lenses comfortable?

Medical History


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PATIENT MEDICAL HISTORY: HAs, Arthritis, Asthma, Diabetes, HBP, Heart, Infl. Bowel Dz, Seizures, Thyroid

Injuries, Surgeries, Hospitalization:

Pregnant Or Nursing:

Primary Care Physcian:       Last Visit:       Reason For Visit:

Systemic Meds:

Drug Allergies:       Allergies:       Birth Control:

OTC:       Vitamins:

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

Social History
Occupation:       Hobbies:

Tobacco: Type: How Long:
Alcohol: Type: How Long:

Review of Systems


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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
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence
MUSCLES, BONES, JOINTS: Athritis, Joint Pains, Head or Neck Injury
SKIN: growths, rashes, acne
NEUROLOGICAL: Headaches, migraines, seizures
PSYCHIATRIC: Depression, Anxiety, Insomnia
ENDORCRINE: Thyroid, Diabetes
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

Child History


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Child History
School:       Grade:
Referred By:

Eyestrain with near work:       Loses place when reading:
Difficulty with writing:       Reading delay:

Math delay:       Letter reversals:       Covers eye when reading:
Uses finger to keep place:       Eye turn:       Double vision:


School Services:

OT:       PT:       Speech:       TVI:       Resource room:

Extra help in reading:       Extra help in math:       Classroom Aide:

504 Accommodations:

IEP:

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