Example Online Patient Form

Demographics

Patient Information

Title: Select Mr. Mrs. Ms. Dr. Rev.	First	Last
MI:	Suffix:	Nickname:

Address:

Apt/Suite #:

City:

State: Select TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Zip Code:

Home Phone:	Work Phone:
Other Phone:	Alerts:
Cell Phone:	Contact Method: Select Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN	Email
Birthday	Occupation
Sex Male Female F	Employment Status Employed Full-Time Student Part-Time Student
Employer/School
Misc/Guardian

Billing Information

Is The Billing Address the Same? Yes

Title: Select Mr. Mrs. Ms. Dr. Rev.	First:	Last:
MI:	Suffix:

Address:

Apt/Suite #:

City:	State: Select TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY	Zip Code:
Home Phone:	Work Phone:

Chief Complaints

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

Chief Complaint:

Reason for Visit:

Secondary Complaints:

Notes:

Past Surgeries

Date:	Type:	Notes:

Major Illnesses

Date:	Type:	Notes:

Demographics

Race:	Select American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Patient Declined to Specify Other
Ethnicity:	Select Hispanic or Latino Not Hispanic or Latino Other Patient Declined to Specify Other
Preferred Language:	Select English French German Spanish Other

Social History

Hobbies:

Smoking Status	Select Never smoker (<100 cigs equiv) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Current every day smoker Unknown if ever smoked Other
Type:	Select None Cigaretts Chewing Tobacco Other
How Long:
Alcohol:	Select No Yes Occasionally Socially Other
Type:	Select None Beer Wine Hard Liquor Other
How Long:
Illegal Drugs:	Select No Yes Other
Type:	Select N/A Other
How Long:

Tobacco Cesssation Counseling?	Select N/A Yes No Other
Past Smoker?	Select No Yes Other
Quit Smoking When?	Select N/A Other
Do you use chewing tobacco?	Select No Yes Other

Marital Status:	Select Married Single Divorced Widowed Other
Engage in regular exercise?	Select Yes No Other
STD:	Select None Gonorrhea Syphilis Hepatitis HIV TB Other

Medical History

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

Patient Medical History

General:	Select None Fatigue Fever Loss of Appetite Weight Gain Weight Loss Developmental Disorders Other
Ear/Nose/Throat:	Select None Neck Problems Sinus Problems Sore Throat (Recent) Headache Morning Headaches Migraine Headache Cluster Headache Hearing Loss Tinnitus Congestion Dry throat / mouth Sleep Apnea Other
Skin:	Select None Acne Lupus Dermatitis Eczema Psoriasis Rosacea Skin Cancer Itching Other
Cardiovascular:	Select None Congestive Heart Disease Cardivascular Disease High Cholesterol Hypertension Arrhythmia Heart Murmur Heart Palpitation Chest Pain Arteriosclerosis Coagulation Disorder Mitral Valve Prolapse Low Blood Pressure Other
Respiratory:	Select None Asthma Cancer: lung Sleep Apnea Sarcoidosis COPD Emphysema Pneumonia Bronchitis Shortness of breath Wheezing Other
Musculoskeletal:	Select None Arthritis Osteoporosis Fibromyalgia Osteoarthritis Muscular Dystrophy Lupus Decreased range of motion Muscle cramps Pain/tenderness Stiffness Swelling Weakness Other
Psychiatric:	Select None Attention Deficit Disorder Anxiety Brain Damage (trauma) Panic Attacks Alzheimers Disease Bi-polar Depression Insomnia Obsessive/Compulsive Paranoia Suicidal Violence Other
Gastrointestinal:	Select None Acid Reflux Crohn's disease Gastric reflux (GERD) IBS Ulcer Gall bladder problems Jaundice Hepatitis Sarcoidosis Cancer: colon Cancer: Liver Other
Endocrine:	Select None Crohn's disease Diabetes Type 1 Diabetes Type 2 Diabetes Suspect Hypothyroid Hyperthoyroid Gout Hormone Replacement Therapy Other
Blood/Lymph:	Select None Anemia Hx of Significant Blood Loss Hematologic Disorder Sickle Cell Disorder Breast Carcinoma Lymph Node Disease Temporal Arthritis Cuts slow to clot Easy bruising Other
Neurological:	Select None Multiple Sclerosis Seizure Disorder Parkinsons Disease Brian Tumor Bells Palsy Dyslexia Headache Balance problems Vertigo Tremors Changes in senses Dementia Memory problems Muscle weakness Numbness, paralysis Personality changes Speech problems Other
Genitourinary:	Select None Amenorrhea Menopause Impotence Jaundice Uterine Cancer Prostate Cancer Kidney Stones Pregnant Nursing Syphilis Prostate Problems Bladder Infections STD- herpetic STD- chlamydia Other
Immune:	Select None Seasonal allergies Environmental allergies Food allergies Drug allergies (please specify) Sjogrens syndrome AIDS Herpes Simplex HIV Simplex Mononucleosis Tuberculosis Cytomegalovirus Infection Herpes Zoster Lyme Disease Sarcoidosis Syphilis Hives Itching Mild allergy symptoms Severe allergy symptoms Swelling Other

Family Medical History

Eye Diseases:	Relationship to Patient:
Amblyopia:	Select No Aunt Brother Cousin Daughter Grandfather Grandmother Father Mother Sister Son Uncle Other
Blindness:	Select No Aunt Brother Cousin Daughter Grandfather Grandmother Father Mother Sister Son Uncle Other
Cataract:	Select No Aunt Brother Cousin Daughter Grandfather Grandmother Father Mother Sister Son Uncle Other
Color Defeciency:	Select No Aunt Brother Cousin Daughter Grandfather Grandmother Father Mother Sister Son Uncle Other
Eye Tumors:	Select No Aunt Brother Cousin Daughter Grandfather Grandmother Father Mother Sister Son Uncle Other
Glaucoma	Select No Aunt Brother Cousin Daughter Grandfather Grandmother Father Mother Sister Son Uncle Other
Macular Degeneration	Select No Aunt Brother Cousin Daughter Grandfather Grandmother Father Mother Sister Son Uncle Other
Retinal Detachment	Select No Aunt Brother Cousin Daughter Grandfather Grandmother Father Mother Sister Son Uncle Other
Strabismus	Select No Aunt Brother Cousin Daughter Grandfather Grandmother Father Mother Sister Son Uncle Other

Systematic Diseases:	Relationship To Patient:
Arthritis:	Select No Aunt Brother Cousin Daughter Grandfather Grandmother Father Mother Sister Son Uncle Other
Cancer:	Select No Aunt Brother Cousin Daughter Grandfather Grandmother Father Mother Sister Son Uncle Other
Diabetes:	Select No Aunt Brother Cousin Daughter Grandfather Grandmother Father Mother Sister Son Uncle Other
Heart Disease:	Select No Aunt Brother Cousin Daughter Grandfather Grandmother Father Mother Sister Son Uncle Other
High Blood Pressure:	Select No Aunt Brother Cousin Daughter Grandfather Grandmother Father Mother Sister Son Uncle Other
Kidney Disease:	Select No Aunt Brother Cousin Daughter Grandfather Grandmother Father Mother Sister Son Uncle Other
Lupus:	Select No Aunt Brother Cousin Daughter Grandfather Grandmother Father Mother Sister Son Uncle Other
Stroke:	Select No Aunt Brother Cousin Daughter Grandfather Grandmother Father Mother Sister Son Uncle Other
Thyroid Disease:	Select No Aunt Brother Cousin Daughter Grandfather Grandmother Father Mother Sister Son Uncle Other

Patient Medical History

Primary Care Physcian:
Last Visit:	Select 1 week 1 month 3 months 6 months 1 year 2 years Other
Reason For Visit:	Select Check up Annual Other

Height:	Ft.	In.
Weight:	Lbs.

Current Medications
Allergy History:

Vitamins:	Select None A E C Zinc Xanten Lutein Other
Over The Counter Medications:	Select None Asprin Acetomenophin Ibuprofen Other
Pregnant Or Nursing:	Select No Yes Unsure Other
Recent Tetanus Shot:	Select Yes No Other

Notes:

Diabetics

Blood Sugar:
Date Blood Sugar was Taken:
HbA1C:
Date HbA1C was Taken:

Visual History

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

Patient Eye Diseases

If yes, how long has this been a problem? Please briefly describe:

Amblyopia:	Select No Yes Other
Blepharitis:	Select No Yes Other
Blindness:	Select No Yes Other
Cataracts:	Select No Yes Other
Color Blindness:	Select No Yes Other
Eye Injuries:	Select No Yes Other
Diabetic Retinopathy:	Select No Yes Other
Glaucoma:	Select No Yes Other
Glaucoma Suspect:	Select No Yes Other
High Risk Medication:	Select No Yes Other
Macular Degeneration:	Select No Yes Other
PVD:	Select No Yes Other
Retinal Detachment:	Select No Yes Other
Strabismus:	Select No Yes Other
Other:	Select No Yes Other

Patient Current Eye Symptoms

If yes, please briefly describe:

Headaches:	Select No Yes Other
Light Sensitivity:	Select No Yes Other
Tired Eyes:	Select No Yes Other
Burning:	Select No Yes Other
Dryness:	Select No Yes Other
Epiphora:	Select No Yes Other
Eyelid Swelling:	Select No Yes Other
Eye Pain or Soreness:	Select No Yes Other
Foreign Body Sensation:	Select No Yes Other
Infection of Eyelid:	Select No Yes Other
Itching:	Select No Yes Other
Mucous:	Select No Yes Other
Ptosis (Drooping Eyelid):	Select No Yes Other
Redness:	Select No Yes Other
Sandy or Gritty Feeling:	Select No Yes Other
Blurred Vision Distance:	Select No Yes Other
Blurred Vision Near:	Select No Yes Other
Distorted Vision:	Select No Yes Other
Double Vision:	Select No Yes Other
Flashes of Lights:	Select No Yes Other
Floaters or Spots:	Select No Yes Other
Fluctuating Vision:	Select No Yes Other
Loss of Vision:	Select No Yes Other
Other:	Select No Yes Other

Additional Notes:

Review of Ocular System

Last Eye Exam:

Select 1 year 2 years 3 years Other

Doctor:

Select Dr. Bishop Dr. Kautz Other

Primary Vision Correction:	Select None Glasses-Full Time Glasses-Readers Only Contacts - Soft RGPs PMMA OTC readers Other
Do you have backup glasses?	Select Yes No Other
Do you want new glasses?	Select Yes No Other

Type of CLs worn in past:	Select None Disposable Conventional Colored RGP PMMA Cobalt Study Lens Soft Other
Cleaner:	Select Optifree Clear Care Boston Renu Other
Disposal:	Select 2 weeks monthly daily weekly yearly Other
Wear Time:	Select >2 hours today All day Occ. Overnight Extended 8 hours 10 hours 12 hours Overnight Other

Hours per Day:
Days per Week:

NOTES:

OSDI

Patient Ocular Information

Rate each of the following from 0-4, where 0=never, 1 = rarely, 2 = sometimes, 3 = often, 4 = always

Experienced the following?
Sensitivity to light?	Select 0 1 2 3 4 Other
Gritty feeling?	Select 0 1 2 3 4 Other
Painful or sore?	Select 0 1 2 3 4 Other
Blurred vision?	Select 0 1 2 3 4 Other
Poor vision	Select 0 1 2 3 4 Other
Limited in performing the following?
Reading?	Select 0 1 2 3 4 Other
Driving at night?	Select 0 1 2 3 4 Other
Computer use?	Select 0 1 2 3 4 Other
Watching TV?	Select 0 1 2 3 4 Other
Uncomfortable in the following?
Windy conditions?	Select 0 1 2 3 4 Other
Low humidty?	Select 0 1 2 3 4 Other
Air conditioning?	Select 0 1 2 3 4 Other

Submit Data

EYECARE CENTER OF SALEM
ACKNOWLEDGMENT AND CONSENT

I understand that The Eyecare Center of Salem (referred to below as "This Practice") will use and disclose health information about me.

I understand that my health information may include information both created and received by the practice, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information.

I understand and agree that This Practice may use and disclose my health information in order to:

• make decisions about and plan for my care and treatment;
• refer to, consult with, coordinate among, and manage along with other health care providers for my care and treatment;
• determine my eligibility for health plan or insurance coverage, and submit bills, claims and other related information to insurance companies or others who may be responsible to pay for some or all of my health care; and
• perform various office, administrative and business functions that support my physician’s efforts to provide me with, arrange and be reimbursed for quality, cost-effective health care.

I also understand that I have the right to receive and review a written description of how This Practice will handle health information about me. This written description is known as a Notice of Privacy Practices and describes the uses and disclosures of health information made and the information practices followed by the employees, staff and other office personnel of This Practice, and my rights regarding my health information.

I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy Practices. I also understand that a copy or a summary of the most current version of This Practice's Notice of Privacy Practices in effect will be posted in waiting/reception area and available on the website at eyecarecenterofsalem.com.

I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that This Practice is not required by law to agree to such requests.

By signing below, I agree that I have reviewed and understand the information above and that I have received a copy of the Notice of Privacy Practices.

Financial Notice (ABN)

The patient's portion of charges is due at the time of service. There will be a service charge on all returned checks. Unpaid accounts will be forwarded to our collection agency. Payment from my insurance is to be paid directly to Eyecare Center of Salem, LLC. I understand that all benefits quoted to me are not a guarantee of payment by my insurance company and that final determination can only be made when the claim is processed.

By signing below, I agree that I have reviewed and understand the information above and that I have received a copy of the Notice of Privacy Practices. Please check, sign and date that you have read, understand, and agree to the above, then click the submit data button to complete your online forms. Thank you!

Check: Patient Signature: Date: