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
Race: Misc/Guardian
Ethnicity: Preferred Language:
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
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: Doctor:

Primary Vision Correction:
Back up specs?: Wants new glasses?:

Type of CLs worn in past:
Cleaner: Disposal:
Wear Time: Days/week: hours comfortably:
Family Ocular History
Glaucoma: Cataracts:
Macular Degen: Retinal Detach:
Crossed / Lazy: Other:
Medications, Allergies, Other History
Systemic Medications:
Take any Vitamins?:
Over The Counter Meds:
Allergies:

Primary Care Physician:
Last Visit: Reason For Visit:
Injuries, Surgeries, Hospitalization:
Patient and Family Medical History
Diabetes: YrDx: HbA1C:

Hypertension:
High Cholesterol:
Thyroid:
Cardiovascular:
Cancer:
Social History
How did you hear about us?:
Hobbies: Occupation:
Pregnant Or Nursing:

Smoking Status:
Alcohol:
Illegal Drugs:

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