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 Employment Status
Marital Status Employer / School Name
Misc/Guardian



Vision

Primary Vision Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:
Secondary Vision Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical

Primary Medical Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:
Secondary Medical Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

Visual History

Please list any eye issues you're currently having:
What pharmacy do you normally use?:

Previous Eye Doctor: Last Eye Exam

Age of Glasses:
Primary Vision Correction:
Type of contacts worn in past: Solution: Disposal:

*Have you ever had any medical attention to your eyes? Please describe:

Past, Current and Family History of Eye Conditions

 YouFamilyNo
Cataract   
Lazy Eye   
Glaucoma   
Computer Vision Syndrome   
Macular Degeneration   
Vitreous Detachment   
Retinitis Pigmentosa   
Retinal Detachment   
Color Blindness   

Please describe any other history of eye disease:
Please describe any other family history of eye disease:

Medical History (problems with bodily systems)

 YouFamilyNo
Diabetes   
Gastroinestinal   
Ear/Nose/Throat   
Cardiovascular   
Respiratory   
High BP   
Nervous System   
Genitourinary   
Musculoskeletal   
Mental System   
Endocrine   
Blood/Lymph   
Allergy/Immune   
Allergies   
Medication Use   

Please describe any other history of medical conditions:
Please describe any other family history of medical conditions:

Do you currently have any allergies?:
Please list any medications you're currently taking:
Vitamins: Over The Counter Meds:

Pregnant Or Nursing?:
Have you had a:     Recent Tetanus Shot?: Recent Flu Vaccine?:

Social History

How often do you use a computer?: Workplace Setting:
Hobbies:

Smoking Status: Type How Long
Alcohol Use: Type: How Long:
Illegal Drug Use: Type: How Long:

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