Online Patient Form

Demographics

Patient Information

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

Title	* First	* Last	MI	Suffix	Nickname	Pronoun
Mr. Mrs. Ms. Dr. Rev.						he/him/his she/her/hers they/them/theirs

* Address:
* City:		* State/ZipCode	OR WA 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 PA RI SC SD TN TX UT VT VI VA WV WI WY

* Home Phone:		Work Phone:
Other Phone:		Alerts:
* Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
* Email
* Birthday		Occupation
* Birth Gender	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed	Employer / School Name
Misc/Guardian

Billing Information

Is The Billing Address the Same?

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

Address

City	State	ZipCode
	OR WA 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 PA RI SC SD TN TX UT VT VI VA WV WI WY

Home Phone:
Work Phone:

Medical History

Patient History

Reason for Visit:

Do you wear glasses?	Y	N
If yes, do you wear them for:	Dist	Near	Both
Do you wear contact lenses?	Y	N

Date of Last Eye Exam:

Date of Last Medical Exam:

Height:

Ft In

Weight:

Lbs

Please list any allergies to medications you have:

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

Please report the FREQUENCY of the following symptoms using the ratings list below
Dryness, Grittiness, or Scratchiness	0 - Never 1 - Sometimes 2 - Often 3 - Constant
Soreness or Irritation	0 - Never 1 - Sometimes 2 - Often 3 - Constant
Burning or Watering	0 - Never 1 - Sometimes 2 - Often 3 - Constant
Eye Fatigue	0 - Never 1 - Sometimes 2 - Often 3 - Constant
0 = Never          1 = Sometimes          2 = Often          3 = Constant

Please report the SEVERITY of the following symptoms using the rating list below
Dryness, Grittiness, or Scratchiness	0 - No Problems 1 - Tolerable - not perfect, but not uncomfortable 2 - Uncomfortable - irritating, but does not interfere with my day 3 - Bothersome - irritating and interferes with my day 4 - Intolerable - unable to perform my daily tasks
Soreness or Irritation	0 - No Problems 1 - Tolerable - not perfect, but not uncomfortable 2 - Uncomfortable - irritating, but does not interfere with my day 3 - Bothersome - irritating and interferes with my day 4 - Intolerable - unable to perform my daily tasks
Burning or Watering	0 - No Problems 1 - Tolerable - not perfect, but not uncomfortable 2 - Uncomfortable - irritating, but does not interfere with my day 3 - Bothersome - irritating and interferes with my day 4 - Intolerable - unable to perform my daily tasks
Eye Fatigue	0 - No Problems 1 - Tolerable - not perfect, but not uncomfortable 2 - Uncomfortable - irritating, but does not interfere with my day 3 - Bothersome - irritating and interferes with my day 4 - Intolerable - unable to perform my daily tasks
0 = No problems
1 = Tolerable - not perfect, but not uncomfortable
2 = Uncomfortable - irritating, but does not interfere with my day
3 = Bothersome - irritating and interferes with my day
4 = Intolerable - unable to perform my daily tasks

Please list any medications you are currently taking:	Please list any eye medications you are currently using:

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

Occupation:

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