Online Patient Form

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Demographics


Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Cell Phone: Home Phone:
Work Phone: Alerts:
Other 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:

Medical History

Review of Ocular System
Reason for Visit:
Secondary Reasons:

Do you have a history of any eye issues? If so, please describe:

Have you had any eye surgeries? If so, please describe:

Do you take any eye medications? If so, please list them:

Last Eye Exam: Doctor:
Primary Vision Correction:
Back up glasses?: Wants new glasses?:
Do you want to be fitted for contact lenses?

If you wear/have worn contact lenses, fill out the info below.

Type of Contacts worn in past:
Cleaner: Disposal: Wear Time:
Days per week worn: Hours worn comfortably:
Review of Systems
General: Ear/Nose/Throat:
Cardiovascular: Genital/Kidney/Bladder:
Respiratory: Muscles/Bones/Joints:
Skin: Gastrointestinal:
Neurological: Allergic/Immunologic:
Psychiatric: Blood/Lymph:
Endocrine:
Medications/Allergies/Other History
Medications: No Medications  Vitamins:
  
Over The Counter Medications:   Allergies to Medications: No Known Drug Allergies
  

Primary Care Physician:
Last Visit: Reason For Last Visit:
Do You Have Diabetes?: Year Diagnosed:  A1C:

Have you had any injuries/surgeries/hospitalizations? If so, please describe:

Pregnant Or Nursing: Recent Tetanus Shot:

Height Weight
Family Medical History Unknown Family History

Does your family have a history of any of these conditions? If so, please choose the affected family member.

Blood Pressure:
Glaucoma:
Cataracts:
Macular Degen:
Diabetes:
Social History
Special Visual Needs:

Occupation: Hobbies: STD's:

Smoking Status: Type: How Long:
Alcohol: Type: How Long:
Illegal Drugs: Type: How Long:

Race: Ethnicity: Preferred Language:

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