Online Patient Form

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Demographics


Required information is marked with a *
 
Patient Information
TitleFirst*Last*MISuffixNickname
Address*:
City: State/ZipCode
Home Phone*: Work Phone:
Other Phone: Cell Phone*:
Contact Method: Email*
SSN* Occupation
Birthday* Hobbies:
Sex* Male Female Employment Status: Employed Full-Time Student Part-Time Student
Marital Status Employer Name:
Primary Doctor:

We at Evolutionary Eye Care strive to you give a truly customized visit.
Please your beverage of choice, and we will try our best to have it ready
for your appointment!*:

Billing Information* Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Vision

If you have a vision plan, please fill out the form completely.

Plan Information
Plan Name*:
Plan ID*:
Plan Policy Group:
Primary on Account* I am Primary (If this is checked, please skip the section below)
Name:Last, First, MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:

Medical

If you have medical insurance, please fill out the form completely.

Primary Medical Insurance
Insurance Name*:
Insurance ID*:
Insurance Policy Group:
Primary on Account* I am Primary (if this is checked, please skip the section below)
Name:Last, First, MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Secondary Medical Insurance
Insurance Name:
Insurance ID:
Insurance Policy Group:
Primary on Account I am Primary (if this is checked, please skip the section below)
Name:Last, First, MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:

Medical History

Ocular History

Do you have a history of these eye conditions?         Does your family have a history of these eye conditions?
                                                                                   Family History Unknown

Glaucoma*: Yes No                               Glaucoma*: None   Mom   Dad   Sibling
Macular Degen*: Yes No                               Macular Degen*: None Mom Dad Sibling
Retinal Problems*: Yes No                               Lazy/Cross Eye*: None Mom Dad Sibling
Cataracts*: Yes No                               Blindness*: None Mom Dad Sibling
Lazy Eye*: Yes No
Vision Loss*: Yes No
Crossed Eyes*: Yes No
Color Blindness*: Yes No
Double Vision*: Yes No

Other Patient Ocular Conditions:                             Other Family Ocular Conditions:
                             
Please type "None" if you've never had any eye surgeries.
Eye Surgeries*:
Eye Injuries:
Medical History

Do you have a history of these medical conditions?

Diabetes*: Yes No    Year Diagnosed: A1c:
Blood Pressure*: Yes No
High Cholesterol*: Yes No
Heart Disease*: Yes No
Thyroid*: Yes No
Cancer*: Yes No
Arthritis*: Yes No
Asthma*: Yes No
Migraines*: Yes No

Other Patient Medical Conditions:

Does your family have a history of these medical conditions?

Diabetes*: None   Mom   Dad   Sibling
Blood Pressure*: None Mom Dad Sibling
Thyroid*: None Mom Dad Sibling
Cancer*: None Mom Dad Sibling

Other Family Medical Conditions:

Please type "None" below if you do not take any medications or have any medication allergies.
Prescription Medications*: Medication Allergies*:
Primary Care Physician:
Social History
Race*: Ethnicity*: Preferred Language*:
Smoking Status*: Alcohol Use*: Illegal Drug Use*:
Review of Systems
Eyes: Allergic/Immunologic:
Endocrine: Musculoskeletal:
Psychiatric: Cardiovascular:
General: Ears, Nose, Throat:
Respiratory: Gastrointestinal:
Neurological: Genitourinary:
Skin: Blood/Lymph:
Chief Complaint
Reason for Visit*:

Are you interested in glasses?   Are you interested in contacts?

Location: Severity: Duration: Timing:
Quality: Context: Modifying: Associated:
Secondary Reasons:

Glasses/Contact Lenses: Please bring previous/current prescription to your exam.

Are You: Interested in LASIK Interested in Laserless Vision Correction (Ortho-K)

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