Online Patient Form

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After completing all the forms, please submit your data on the final tab. Thank you!

Demographics


Patient Information
All fields in red marked with asterisks are required to be filled out. Thank you!

Title* First* LastMISuffixNickname
* Address:
* City: * State/ZipCode
* Home Phone: Work Phone:
Other Phone: Alerts:
* Cell Phone: Preferred Contact Method:
* Email
* Birthday Occupation
* Gender 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:

Medical History


Patient History
Reason for Visit:

Do you wear glasses? YN
If yes, do you wear them for: DistNearBoth
Do you wear contact lenses? YN

Date of Last Eye Exam: Date of Last Medical Exam:

Do you have allergies to medication? YN
Please list:

Do you have seasonal allergies? YN
Are you taking medications? YN
Are you pregnant? YN
Do you see flashes of light in your eyes? YN
Do you see floating objects in your eyes? YN
Do you have temporary blackouts of your vision? YN
Do you have frequent headaches? YN
Do you use tobacco? YN
Do you drink alcohol? YN

Please list medications: Please list eye medications:

Do you have:
NONE
High Blood Pressure
Diabetes
Lung Disease
Cancer
Rheumatoid Arthritis
Previously
Seizures
Multiple Sclerosis
HIV
          Have you ever had?
          NONE
          Strabismus (eye turn)
          Amblyopia (lazy eye)
          Keratoconus
          Glaucoma
          Diabetic Retinopathy
          Macular Degeneration
          Dry Eyes
          Iritis
          Retinal Detachment
          Retinal Disease
          Optic Nerve Disease
          Have you ever had eye surgery for:
          NONE
          Cataract
          Retinal Detachment
          Muscle Surgery
          Trauma
          Lasik/PRK
          Foreign Body Removal
          Other
          Has anyone in your family ever had:
          NONE
          Blindness
          Glaucoma
          Diabetes
          Cataracts
          Macular Degeneration
          Keratoconous

Avg. Hrs/day spent on computer:
          Occupation:
         

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