Online Patient Form

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

Demographics

Title	First	Last	MI	Suffix	Nickname

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
Primary Doctor		Misc/Guardian

Billing Information Is The Billing Address the Same?

Title	First	Last	MI	Suffix

Address

City	State	ZipCode

Home Phone:
Work Phone:

Medical History

Review of Ocular System

Ocular History:

Eye Meds:

Last Eye Exam:

By Doctor:

Primary Vision Correction:

Back up glasses?

Wants new glasses?

Fill out the next section only if you have worn contacts.

Type of CLs worn in past:

Cleaner:

Disposal:

Wear Time:

Days per week worn:

Hours comfortably worn:

Family History

Family Eye History

Does your family have a history of these eye conditions? Unknown family history

Macular Degen:		Glaucoma:
Retinal Detach:		Cataracts:
Crossed/Lazy Eye:

Family Medical History

Does your family have a history of these medical conditions?

Medical History

Prescribed Medications: No Medications	Drug Allergies: No Known Drug Allergies

Primary Care Physician:

Last Visit:

Reason:

Injuries, Surgeries, Hospitalization

Pregnant Or Nursing:

Recent Tetanus Shot:

Height:

ft.

in.

Weight:

Social History

Occupation:

Hobbies:

STD:

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

Race:

Ethnicity:

Preferred Language:

Review of Systems

General:		Ear/Nose/Throat:
Respiratory:		Genital/Kidney/Bladder:
Skin:		Cardiovascular:
Psychiatric:		Muscles/Bones/Joints:
Endocrine:		Gastrointestinal:
Neurological:		Allergic/Immunologic:
Blood/Lymph:

Online Patient Form

Demographics

Medical History

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