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
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip Code:
Home Phone:
Work Phone:
Other Phone:
Alerts:
Cell Phone:
Preferred Contact Method:
Home Phone
Work Phone
Cell Phone
Other Phone
Text Message
Email
SSN
Email
Birthday
Occupation
Sex
Male
Female
Employment Status
Employed
Full-Time Student
Part-Time Student
Marital Status
Annulled
Divorced
Domestic partner
Interlocutory
Legally Separated
Married
Never Married
Polygamous
Widowed
Employer / School Name
Misc/Guardian
Billing Information
Is The Billing Address the Same?
Yes
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
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:
No Meds Used
Over The Counter Medications:
Vitamins:
Drug Allergies:
No Known Drug Allergies
Please describe any injuries or surgeries you have had:
Primary Care Physician:
Last Visit:
1 week
1 month
3 months
6 months
1 year
2 years
greater than 3 years
Other
Reason:
Check up
Annual
Specific
Other
Pregnant Or Nursing:
No
Yes
Unsure
Other
Recent Tetanus Shot:
Yes
No
Other
Do you or any family members have any of these medical conditions?
Unknown family history
Self
Family
Describe:
Diabetes:
No
Yes
None
Mother
Father
Grandparent
Sibling
Unknown
Other
High BP:
No
Yes
None
Mother
Father
Grandparent
Sibling
Unknown
Other
High Cholesterol:
No
Yes
None
Mother
Father
Grandparent
Sibling
Unknown
Other
Thyroid Disease:
No
Yes
None
Mother
Father
Grandparent
Sibling
Unknown
Other
Heart Disease:
No
Yes
None
Mother
Father
Grandparent
Sibling
Unknown
Other
Rheumatoid Arthritis:
No
Yes
None
Mother
Father
Grandparent
Sibling
Unknown
Other
Lupus:
No
Yes
None
Mother
Father
Grandparent
Sibling
Unknown
Other
Cancer:
No
Yes
None
Mother
Father
Grandparent
Sibling
Unknown
Other
Eye History
Do you currently have any of these symptoms?:
None
Itching
Burning, Stinging
Red
Floaters
Flashes Of Light
Eye Injuries
Eye Surgery
Amblyopia
Strabismus
Cataracts
Glaucoma
Retinal Disorders
Other
Do you take any of these eye medications?:
None
Cromolyn NA 4%
Visine
Patanol
Xalatan
Travatan
rewetting drops
Elestat
Vigamox
Alphagan
Refresh
Theratears
Genteal
Pred Forte
Lotemax
Alrex
Systane
Blink
Other
Last Eye Exam:
1 year
2 years
3 years
Other
By Doctor:
Primary Vision Correction:
None
Prescription Glasses
Prescription Reading Glasses
Soft Contacts
Non-Prescription Reading Glasses
Other
Do you: Have back up glasses?
No
Yes
Other
Want new glasses?
Yes
No
Other
Contact Lens Wearers only
Type of contacts worn in the past:
Cleaner:
Disposal:
Wear Time:
Family Eye History
Macular Degen:
No
Parents
Siblings
Grandparent
Other
Glaucoma:
No
Parents
Sibling
Grandparent
Other
Retinal Detach:
No
Parents
Siblings
Grandparent
Other
Cataracts:
No
Parents
Siblings
Grandparent
Other
Lazy/Crossed Eye:
No
Parents
Siblings
Grandparent
Other
Blindness:
No
Parents
Siblings
Grandparent
Other
Review of Systems
General:
None
Fatigue
Fever
Loss of Appetite
Weight Gain
Weight Loss
Developmental Disorders
Other
Ear/Nose/Throat:
None
Neck Problems
Sinus Problems
Sore Throat (Recent)
Headache
Morning Headaches
Migraine Headache
Cluster Headache
Hearing Loss
Tinnitus
Congestion
Dry throat / mouth
Sleep Apnea
Other
Skin:
None
Acne
Lupus
Dermatitis
Eczema
Psoriasis
Rosacea
Skin Cancer
Itching
Other
Cardiovascular:
None
Congestive Heart Disease
Cardiovascular Disease
High Cholesterol
Hypertension
Arrhythmia
Heart Murmur
Heart Palpitation
Chest Pain
Arteriosclerosis
Coagulation Disorder
Mitral Valve Prolapse
Low Blood Pressure
Other
Respiratory:
None
Asthma
Cancer: lung
Sleep Apnea
Sarcoidosis
COPD
Emphysema
Pneumonia
Bronchitis
Shortness of breath
Wheezing
Other
Musculoskeletal:
None
Arthritis
Osteoporosis
Fibromyalgia
Osteoarthritis
Muscular Dystrophy
Lupus
Decreased range of motion
Muscle cramps
Pain/tenderness
Stiffness
Swelling
Weakness
Other
Psychiatric:
None
Attention Deficit Disorder
Anxiety
Brain Damage (trauma)
Panic Attacks
Alzheimer's Disease
Bi-polar
Depression
Insomnia
Obsessive/Compulsive
Paranoia
Suicidal
Violence
Other
Gastrointestinal:
None
Acid Reflux
Crohn's disease
Gastric reflux (GERD)
IBS
Ulcer
Gall bladder problems
Jaundice
Hepatitis
Sarcoidosis
Cancer: colon
Cancer: Liver
Other
Endocrine:
None
Crohn's disease
Diabetes Type 1
Diabetes Type 2
Diabetes Suspect
Hypothyroid
Hyperthyroid
Gout
Hormone Replacement Therapy
Other
Blood/Lymph:
None
Anemia
Hx of Significant Blood Loss
Hematologic Disorder
Sickle Cell Disorder
Breast Carcinoma
Lymph Node Disease
Temporal Arthritis
Cuts slow to clot
Easy bruising
Other
Neurological:
None
Multiple Sclerosis
Seizure Disorder
Parkinson's Disease
Brain Tumor
Bells Palsy
Dyslexia
Headache
Balance problems
Vertigo
Tremors
Changes in senses
Dementia
Memory problems
Muscle weakness
Numbness, paralysis
Personality changes
Speech problems
Other
Genitourinary:
None
Amenorrhea
Menopause
Impotence
Jaundice
Uterine Cancer
Prostate Cancer
Kidney Stones
Pregnant
Nursing
Syphilis
Prostate Problems
Bladder Infections
STD- herpetic
STD- chlamydia
Other
Immune:
None
Seasonal allergies
Environmental allergies
Food allergies
Drug allergies (please specify)
Sjogren's syndrome
AIDS
Herpes Simplex
HIV Simplex
Mononucleosis
Tuberculosis
Cytomegalovirus Infection
Herpes Zoster
Lyme Disease
Sarcoidosis
Syphilis
Hives
Itching
Mild allergy symptoms
Severe allergy symptoms
Swelling
Other
Social History
Hobbies:
None
Art
Baseball
Astronomy
Boating
Basketball
Cooking
Crafts
Dancing
Diving
Football
Fishing
Golf
Gardening
Horseback Riding
Hunting
Models
Needlepoint
Painting
Photography
Piano
Reading
Running
Roller Blading
Softball
Sewing
Skiing
Soccer
Swimming
Tennis
Video Games
Woodworking
Other
STD's:
None
Gonorrhea
Syphilis
Hepatitis
HIV
TB
Other
Smoking Status:
Never smoker (<100 cigs equiv)
Former smoker (no longer smokes)
Current some day smoker (not daily)
Light smoker (<10 cigs/day)
Heavy smoker (>10 cigs/day)
Smoker (current status unknown)
Current every day smoker
Unknown if ever smoked
Other
Type:
None
Cigarettes
Chewing Tobacco
Other
How Long:
Alcohol Use:
No
Yes
Occasionally
Socially
Other
Type:
None
Beer
Wine
Hard Liquor
Other
How Long:
Illegal Drug Use:
No
Yes
Other
Type:
How Long
Race:
White
Black or African American
Asian
Patient Declined to Specify
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Other Race
Other
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Unknown
Patient Declined to Specify
Other
Preferred Language:
English
French
German
Spanish
Other
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:
Yes
No
Frequent eye rubbing:
Yes
No
Tires easily:
Yes
No
Difficulty recognizing same word on different page:
Yes
No
Difficulty with memory:
Yes
No
Remembers better what's heard than said:
Yes
No
Responds better orally than by writing:
Yes
No
Seems to know material, but does poorly on tests:
Yes
No
Dislikes/avoid near tasks:
Yes
No
Short attention span/loses interest:
Yes
No
Dislikes/avoids sports:
Yes
No
Difficulty catching/hitting a ball:
Yes
No
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?:
Yes
No
Did the mother experience any health problems during the pregnancy?:
Yes
No
If yes, explain:
Normal birth?:
Yes
No
If yes, explain:
Birth weight:
Visual History
Has your child's vision been previously evaluated?:
Yes
No
If so, Doctor's Name:
Date of last evaluation:
Reason for examination:
Results and recommendations:
Were glasses, contact lenses, or other optical devices recommended?:
Yes
No
If yes, what?
Are they used?:
Yes
No
If yes, when?
If not used, why not?
Members of the family who have had visual attention and the reason:
Name
Age
Visual Condition
School
Age at time of entrance to: Preschool
Kindergarten
First Grade
Does your child like school?:
Yes
No
Does your child like to read?:
Yes
No
Voluntarily?:
Yes
No
Does your child read for pleasure?:
Yes
No
Overall schoolwork is:
Above Average
Average
Below Average
Which Subjects Are:
Above Average:
Average:
Below Average:
Does your child need to spend a lot of time/effort to maintain this level of performance?:
Yes
No
How much time on average does your child spend each day on homework assignments?:
Do you feel your child is achieving up to potential?:
Yes
No
Does the teacher feel your child is achieving up to potential?:
Yes
No
General Behavior
Are there any behavior problems at school?:
Yes
No
If yes, what?
Are there any behavior problems at home?:
Yes
No
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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