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

CityStateZipCode
Home Phone:
Work Phone:

Primary

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

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:

Tertiary

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
Reason for Visit:
Secondary Reasons:
Last Eye Exam: By Doctor:


Ocular History (Please check all that apply)

Blur at Distance (Driving) Blur at Near (Reading)
Difficulty seeing at night Light Sensitivity
Itchy Eyes Red Eyes
Watery Eyes Dry Eyes
Eye Pain Burning Eyes
Headaches Double Vision
Glare / Halos Seeing Floaters
Seeing Flashes Other


Eye Medications:


Does your family have a history of these eye conditions? If yes, please select which family member.

Macular Degeneration: Glaucoma:
Retinal Detachment: Cataracts:
Diabetic Retinopathy:

Current Medical History

Have you had any major injuries or surgeries? If so, please describe:

Pregnant Or Nursing:
Primary Care Physician: Phone #: Last Exam:
Vitamins:

Systemic Meds: No Current Medications

Drug Allergies: No Known Drug Allergies
Over the Counter Medications:

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

Review of Systems

Eyes: (Ex. Glaucoma, Cataract, Lazy Eye, Retinal Disease)
Endocrine: (Ex. Diabetes, Thyroid Dysfunction, Hormonal Dysfunction)
Cardiovascular: (Ex. HTN, Heart Surgery, Vascular Disease)
General: (Ex. Weight Gain, Weight Loss, Fever, Fatigue)
Ear/Nose/Throat: (Ex. Allergies, Hay Fever, Ear Infection, Sinus Congestion)
Respiratory: (Ex. Asthma, Bronchitis, Emphysema, COPD)
Gastrointestinal: (Ex. Crohn's Disease, Colitis, Ulcer, Digestive Problems)
Genitourinary: (Ex. Urinary Tract Infection, Kidney Infection, Ovarian/Prostate Cancer)
Skin: (Ex. Eczema, Rosacea Acne, Psoriasis, Skin Cancer)
Musculoskeletal: (Ex. Fibromyalgia, Muscular Dystrophy, Arthritis, Ankylosing Spondylitis)
Neurological: (Ex. Multiple Sclerosis, Alzheimer's, Seizures, Stroke, Parkinson's)
Blood/Lymph: (Ex. Anemia, Leukemia, Bleeding Disorder)
Allergic/Immune: (Ex. Drug Allergies, Environmental Allergy, RA, Lupus, AIDS, HIV)
Psychiatric: (Ex. Depression, Panic Disorder, Schizophrenia, Drug Dependence)
Pregnant or Nursing?
Other:

Social History

Hobbies: Hours on Computer:

Smoking Status
Illegal Drug Use: Type: How Long?
Alcohol Use: How much per week?

Preferred Language: Race: Ethnicity:

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