Online Patient Form

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After completing all the forms, please submit your data on the final tab. Thank you!

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
Primary Doctor Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Primary

Insurance Information
Insurance Name:
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

Insurance Information
Insurance Name:
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


Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Chief Complaint
Reason for Visit:
Location: Severity: Quality: Duration:
Timing: Context: Modifying: Associated:

Secondary Reasons:
Location: Severity: Quality: Duration:
Timing: Context: Modifying: Associated:
Review of Ocular System
Please describe any eye problems/conditions you have/had:

Eye Medications: Last Eye Exam: By Doctor:

Primary Vision Correction: Back up glasses?: Want new glasses?:

Fill out this section only if you wear/have worn contact lenses.
Type of contacts worn in past:
Cleaner: Disposal: Wear Time:
Days per week worn: Hours worn comfortably:

Previous Eye Surgeries

1.
Type of Surgery: Surgeon:
Where: When:
Results/Complications:

2.
Type of Surgery: Surgeon:
Where: When:
Results/Complications:

Family Ocular History

Does your family have a history of these conditions? If yes, please choose the affected family member.
Macular Degen: Glaucoma: Cataracts:
Retinal Detach: Blind: Lazy Eye:
Crossed Eyes:
Review of Systems
General: Ear/Nose/Throat:
Skin: Genital/Kidney/Bladder:
Neurological: Cardiovascular:
Psychiatric: Muscles/Bones/Joints:
Respiratory: Allergic/Immunologic:
Endocrine: Blood/Lymph:
Gastrointestinal:
Medical History
Vitamins: Over the Counter Medications:
 

Primary Care Physician: Last Visit: Reason For Visit:
Pregnant Or Nursing: Injuries, Surgeries, Hospitalizations?:

Do you have a history of these conditions? If yes, please describe.
Diabetes: Describe: Year Diagnosed: HbA1C:
Blood Pressure: Describe:
High Cholesterol: Describe:
Thyroid: Describe:
Cardiovascular: Describe:
Cancer: Describe:
Social History
Occupation: Hobbies: STD's:

Do you drive?: Any issues?:
Computer Use: Hours per day: Monitor Height: Distance:
Reads: Do you Require:

Smoking Status: Type: How Long:
Alcohol Use: Type: How Long: Amount:
Illegal Drugs: Type: How Long:

Race: Ethnicity: Preferred Language:

Submit Data