Online Patient Form
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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
Weight:
Lb
Do you have allergies to medication?
Y
N
Please list:
Do you have seasonal allergies?
Y
N
Are you taking medications?
Y
N
Are you pregnant?
Y
N
Do you see flashes of light in your eyes?
Y
N
Do you see floating objects in your eyes?
Y
N
Do you have temporary blackouts of your vision?
Y
N
Do you have frequent headaches?
Y
N
Do you use tobacco?
Y
N
Do you drink alcohol?
Y
N
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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