Online Patient Form

Click here to return to the the previous website.

Instructions:
Please fill out these forms as completely as possible. The information collected will be reviewed by the doctors and staff to be used to:
A. Better understand your unique visual needs
B. Discover any medical risks to your vision or health
C. Utilize any vision or medical insurance benefits to your maximum benefit

After completing all information, please submit your data at the bottom of the page. All fields are required with the exception of the contact lens history section of this form. Please choose "none" if options under the medical history or review of systems does not apply to you. If you currently do wear contact lenses, please complete that section of the form. Thank you!

Patient Information

Title	Legal- First	Last
MI	Suffix
Nickname

Address:
Apt/Suite #:
City:
State:
ZipCode:

We have your contact number on file. Please call our office if you need to update or change your contact number.

Email:
Preferred Contact Method:
Guardian/Advocate/ Interpreter:
Relationship to Patient:
Birthdate:
Sex:	Male Female
Occupation / Grade Level:
Employer / School:
Language:
Ethnicity:
How were you referred?:

Special Considerations (wheelchair, hard of hearing, pregnant, etc.):

Billing Information Is The Billing Address the Same?
Yes

Title	First	Last
MI	Suffix

Address

City

State

ZipCode

Home Phone:
Work Phone:

Visual Tasks:

	Hours per Day/Frequency
Reading:
Computer Use:
Activities:
Driving:
Pilot

Eyes Dry or Uncomfortable	Yes	No
Vision Changes Throughout the Day	Yes	No
Red Eyes	Yes	No
Need or Use Drops	Yes	No

Contact Lens History (If Known)

Current Lenses

Brand:

Power:	R	L
Cyl:	R	L
Axis:	R	L
Base Curve:	R	L

Wear Style:

Schedule:

How old are your current contacts?:
Current Solution:

Medical History

Medical, Personal and Family History

Last Eye Doctor:
Last Eye Exam (estimate)
Primary Care Physician:
Last Medical Exam with PCP:
Eye History:

Please List all Eye Surgeries/Injuries/Vision Therapy:

None	Blepharoplasty
Cataracts	Glaucoma Surgery
Injections	Laser Photocoagulation
Lasik/PRK	Radial Keratotomy
Retinal Surgery	Strabismus
Yag Capsulotomy	Other:

Do you experience any of the following symptoms?:
None	Eye Pain
Light Sensitivity	Fluctuating Vision
Double Vision	Flashes of Light
Change in Near Vision	Change in Distance Vision
Itchy Eyes	Mucous Discharge
Crusty Lids	New Floaters
Excess Tearing	Dry or Burning Eyes
Gritty Feeling	Redness
Tired/Irritated Eyes	Other:

If you have multiple choices for the questions below, please choose one, then add a comma and begin typing the rest.


Please list all eye meds you're currently using, including, over-the-counter & non-prescription drops:
No Drops

Please list all prescription medications you are currently taking, including non-prescription supplements:
No current medications

Vitamins, tobacco, recreational drugs, etc.

Any Medication Allergies?	Family Med History:
No known drug allergies	None Known
Penicillin	Crossed Eyes (Strabismus)
Sulfa	Diabetes
Other:	Hypercholesterolmnia
	Hypertension
	Macular Degeneration
	Glaucoma
	Other:

Review of Systems

Cardiovascular

None

Hypertension

High Cholesterol

Vascular Disease

Heart Disease

Heart Surgery

Stroke/TIA

Other:

Gastrointestinal

None

Crohn's Disease

Inflammatory Bowel Disease

Other:

Skin

None

Rash

Rosacea

Basal Cell Carcinoma

Sjogren's

Scleroderma

Other:

Cancer

None

Breast

Eye

Eyelid

Melanoma

Leukemia

Restricted Limbs

Dialysis Patient

Other:

Immune

None

AIDS/HIV

Allergies

Lupus

Other:

Eye Health Check

During your exam we will check the health of your eyes either by Optomap retinal imaging or dilating your eyes with eye drops.

Please choose one of the following methods for checking the health of your eyes:

Optomap is the doctor's preferred method to check your eye health and a convenient alternative that has no lasting side effects. It provides a digital image that can be used to track the history of your eye health. This service is offered for an additional $39.00.

With dilation be prepared for light sensitivity and near vision blur for about 4 hours. Remember to bring sunwear and/or a driver if you feel it is necessary. Dilation is included in the exam price.

Please read before you submit your online form

Thank you for choosing Coffman Vision Clinic for your eye health needs. At Coffman Vision
Clinic we focus on personal education to prescribe the best treatments, services, and products.
We strive to make a positive difference in our patient's lives as well as our community.

As a courtesy to you, we contact your insurance company to obtain your benefit information.
The insurance company quotes are estimates only and are not a guarantee of payment. Your
co-pay, any deductibles not met, and non-covered services are expected at the time of service.
Any fees not paid by the insurance company are your responsibility.

Thank you for taking the time to complete your online health history form. We ask that you give us at least 24-hour's notice if you need to cancel or reschedule an appointment.

HIPAA and Financial Policy Acknowledgment

By checking this box, you agree that you have read and understand our Notice of Privacy
Practices and agree to our Financial Policy. Our Notice of Privacy Practices and Financial
Policy can be found on our website: www.coffmanvision.com/privacy-policy/.

**Please click the submit button only ONCE to submit your information**