Patient Forms

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname

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		Drivers License #

Is the Billing Address Different?

Vision Insurance

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:

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:

Chief Complaint / Medical History

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Last EE		Occupation		Hobbies
LEE Location		Employer/School		Computer Time

How did you hear about us?		Race		Orientation to P/P/T:
Referred By:		Ethnicity		Preferred Language

Appointment Type

CHIEF COMPLAINT

Secondary Issues:

Personal Ocular History

Eye Dz's or Conditions		Eye Surgeries - Ant Seg:
Eye Injuries		Eye Surgeries - Post Seg:

Vision Correction

Ever worn Glasses?		Ever worn Contact Lens?		Have back up specs?
Wanting new glasses?		Need New Contact Lens?		Interested in trying CL's?

Personal Medical History

Pregnant or Nursing?

No

Yes

Due Date

No current medications

Current Medications Drops (Prescription, Over The Counter)	Taken For (Reason / Disease / Condition):

No known drug allergies

Medication Allergies:

Eye Meds:

Eye Vitamins:

Family Ocular History

Adopted: FHx Unknown

Cataracts:	Retinal Detachment:	Hypertension:	Cancer:
Glaucoma:	Strabismus / Amblyopia:	Hyperlipidemia:	Diabetes:
Macular Degeneration:	Notes:	Heart Disease:	Other:

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Review Of Systems

Review Of Systems

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
KIDNEY, BLADDER: Kidney Stones, Frequent Urination, Pain
MUSCLES, BONES, JOINTS: Arthritis, 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

If Diabetes Year Diagnosed

Latest A1c

Controlled?

Tx:

Primary Care Physcian:
Last Visit:
Reason For Visit:
Injuries, Surgeries, Hopitalizations:

Social History

Smoking Status:
Discussed Cessation?
Do you drink alcohol?

Height	FT	IN
Weight	LBS

Online Patient Form

Demographics

Vision Insurance

Primary

Secondary

Tertiary

Chief Complaint / Medical History

Review Of Systems

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City	State	ZipCode