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
Primary Care Doctor
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Vision

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

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:

Additional

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


Chief Vision Issues For This Visit

Secondary Vision Issues For This Visit:

DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?

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
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury
SKIN: growths, rashes, acne
NEUROLOGICAL: Headaches, migraines, seizures
PSYCHIATRIC: Depression, Anxiety, Insomnia
 ENDOCRINE: Thyroid, Diabetes
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, M.S., Lupus, HIV
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

PATIENT MEDICAL HISTORY

Please list any Injuries, Surgeries, Hospitalization

Pregnant Or Nursing:

Primary Care Physician: Last Visit:

List any Vitamins you take:

Please list any over the Counter medications:

Please list your current Prescription Medications: No Current Medications

Please list all drug allergies: No Known Drug Allergies

Smoking Status:

Alcohol:




PATIENT OCULAR HISTORY

Please select if you have had any of the following:

Please select your current Eye Meds:

Last Eye Doctor: Last Eye Exam:  

Primary Vision Correction: 

Type of CLs worn in past:  Wear Time: Disposal:

FAMILY OCULAR HISTORY

Glaucoma: Crossed / Lazy: Retinal Detach: Macular Degeneration: Cataracts:




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