Online Patient Form
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Demographics
Patient Information
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
City:
State/ZipCode
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
Home Phone:
Work Phone:
Other Phone:
Alerts:
Cell Phone:
Preferred Contact Method:
Home Phone
Work Phone
Cell Phone
Other Phone
Text Message
Email
SSN
Email
Birthday
Occupation
Sex
Male
Female
Employment Status
Employed
Full-Time Student
Part-Time Student
Marital Status
Single
Married
Separated
Divorced
Widowed
Employer / School Name
Race:
(Declined)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Other
Misc/Guardian
Ethnicity:
(Declined)
Hispanic or Latino
Not Hispanic or Latino
Other
Preferred Language:
English
Spanish
Other
Billing Information
Is The Billing Address the Same?
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Address
City
State
ZipCode
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
Home Phone:
Work Phone:
Medical History
Review of Ocular Systems
Please list any eye problems that you are CURRENTLY experiencing (i.e. burning, itching, floaters, redness, etc.):
Please list any previous eye surgeries OR eye conditions with which YOU have been diagnosed (i.e. LASIK, cataract surgery, glaucoma, macular degeneration, retinal detachment, lazy eye, etc.):
Please list any medications you are currently using for your eyes:
Last Eye Exam:
1 year
2 years
3 years
Other
Doctor:
Primary Vision Correction:
None
Glasses-Full Time
Glasses-Readers Only
Contacts - Soft
RGPs
OTC readers
Other
Back up specs?:
No
Yes
Wants new glasses?:
Yes
No
Type of CLs worn in past:
None
Soft
Colored
RGP
Other
Cleaner:
None
PureMoist
Optifree
Clear Care
Boston
Renu
Biotrue
Aquify
Other
Disposal:
daily
2 weeks
monthly
weekly
yearly
Other
Wear Time:
>2 hours today
All day
Occ. Overnight
Extended
8 hours
10 hours
12 hours
Overnight
Other
Days/week:
hours comfortably:
Family Ocular History
Glaucoma:
No
Parents
Sibling
Grandparent
Other
Cataracts:
No
Parents
Siblings
Grandparent
Other
Macular Degen:
No
Parents
Siblings
Grandparent
Other
Retinal Detach:
No
Parents
Siblings
Grandparent
Other
Crossed / Lazy:
No
Parents
Siblings
Grandparent
Other
Other:
Medications, Allergies, Other History
Systemic Medications:
Take any Vitamins?:
Over The Counter Meds:
Allergies:
Primary Care Physician:
Doesn't Remember
Doesn't Have One
Other
Last Visit:
1 week
1 month
3 months
6 months
1 year
2 years
greater than 3 years
Other
Reason For Visit:
Check up
Annual
Specific
Other
Injuries, Surgeries, Hospitalization:
None
Other
Patient and Family Medical History
Diabetes:
None
Self
Mother
Father
Grandparent
Unknown
Other
Type 2
Type 1
Other
YrDx:
1 yr
2 yrs
3-5 yrs
5-10 yrs
10+ yrs
Other
HbA1C:
doesn't know
Other
Hypertension:
None
Self
Mother
Father
Grandparent
Unknown
Other
High Cholesterol:
None
Self
Mother
Father
Grandparent
Unknown
Other
Thyroid:
None
Self
Mother
Father
Grandparent
Unknown
Other
Cardiovascular:
None
Self
Mother
Father
Grandparent
Unknown
Other
Cancer:
None
Self
Mother
Father
Grandparent
Unknown
Other
Social History
How did you hear about us?:
Hobbies:
Occupation:
Pregnant Or Nursing:
No
Yes
Unsure
Smoking Status:
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
Alcohol:
No
Yes
Occasionally
Socially
Other
Illegal Drugs:
No
Yes
Other
Submit Data