Online Patient Form

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After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!

Patient Information

City: State: Zip Code:
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name

Billing Information

Is The Billing Address the Same?
City: State: Zip Code:
Home Phone:
Work Phone:

Medical History

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

Medications: Over The Counter Medications:
Vitamins: Drug Allergies:
Please describe any injuries or surgeries you have had:

Primary Care Physician: Last Visit: Reason:
Pregnant Or Nursing: Recent Tetanus Shot:

Do you or any family members have any of these medical conditions?

High BP:
High Cholesterol:
Thyroid Disease:
Heart Disease:
Rheumatoid Arthritis:

Eye History

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:
Last Eye Exam: By Doctor:

Primary Vision Correction:
Do you:    Have back up glasses? Want new glasses?

Contact Lens Wearers only
Type of contacts worn in the past: Cleaner: Disposal:
Wear Time:

Family Eye History

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

Review of Systems

General: Ear/Nose/Throat:
Skin: Cardiovascular:
Respiratory: Musculoskeletal:
Psychiatric: Gastrointestinal:
Endocrine: Blood/Lymph:
Neurological: Genitourinary:

Social History

Hobbies: STD's:

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

Race: Ethnicity: Preferred Language:

Child Vision History

Why do you feel your child needs a Myopia Control evaluation?
How Old was your child when they got their first Eyeglass Prescription?

Have you noticed or has your child reported any of the following:

Difficulty copying from the chalkboard:
Frequent eye rubbing:
Tires easily:
Difficulty recognizing same word on different page:
Difficulty with memory:
Remembers better what's heard than said:
Responds better orally than by writing:
Seems to know material, but does poorly on tests:
Dislikes/avoid near tasks:
Short attention span/loses interest:
Dislikes/avoids sports:
Difficulty catching/hitting a ball:

Leisure Time Activities

How many Hours per day does your child spend outside - average?
How many Hours per day does your child spend indoors - reading/cellphone/tablet use?

Developmental History

Full-term Pregnancy?:
Did the mother experience any health problems during the pregnancy?:
If yes, explain:

Normal birth?:
If yes, explain:
Birth weight:

Visual History

Has your child's vision been previously evaluated?:
If so, Doctor's Name: Date of last evaluation:
Reason for examination:
Results and recommendations:

Were glasses, contact lenses, or other optical devices recommended?:
If yes, what?
Are they used?:
If yes, when?
If not used, why not?

Members of the family who have had visual attention and the reason:

Name Age Visual Condition


Age at time of entrance to: Preschool Kindergarten First Grade
Does your child like school?:

Does your child like to read?:
Does your child read for pleasure?:

Overall schoolwork is:

Which Subjects Are:
Above Average:
Below Average:

Does your child need to spend a lot of time/effort to maintain this level of performance?:
How much time on average does your child spend each day on homework assignments?:
Do you feel your child is achieving up to potential?:
Does the teacher feel your child is achieving up to potential?:

General Behavior

Are there any behavior problems at school?:
If yes, what?
Are there any behavior problems at home?:
If yes, what?
What causes these problems?

Give a brief description of your child as a person:

Is there any other information you feel would be helpful/important in our treatment of your child?

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