Online Patient Form

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

**Items marked in red are important and must be filled out.**

Demographics


First Name: Last Name: MI: Nickname:
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone:
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
Parent/Guardian


Guardian or Billing Information Is The Billing Address Different?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Vision Insurance

Insurance Name:
Insurance ID (or last 4 of SSN):
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 Insurance

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

Chief Complaint

Reason for Visit:
Secondary Reasons:


Review of Ocular System

Ocular History: (ex. Itching, Burning, Flashes of Light, Injuries, Surgeries, Glaucoma, Cataracts)
Eye Drops:
Last Eye Exam:

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

Type of contacts worn:
Cleaner: Disposal: Wear Time:
Days per week worn: Hours worn comfortably:


Medical History

Medications: No medications Over The Counter Meds:
Vitamins: Allergies: No Known Drug Allergies


Primary Care Physician: Last Visit:
Injuries, Surgeries, Hospitalization:
Pregnant Or Nursing:


Family Ocular History

Does your family have a history of these eye conditions?

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


Review of Systems

General: (ex. Fatigue, Weight Gain/Loss)
Ear/Nose/Throat: (ex. Congestion, Sinus Problems, Dry Throat/Mouth, Headaches)
Respiratory: (ex. Asthma, Emphysema, COPD)
Cardiovascular: (ex. High Blood Pressure, High Cholesterol, Heart Disease)
Skin: (ex. Acne, Eczema, Psoriasis, Rosacea)
Genital/Kidney/Bladder: (ex. Overactive/Underactive Bladder)
Neurological: (ex. Muscle Weakness, Numbness, Paralysis, Speech Problems, Tremors)
Muscles/Bones/Joints: (ex. Arthritis, Stiffness, Swelling, Weakness)
Psychiatric: (ex. Anxiety, Depression)
Gastrointestinal: (ex. Abdominal Pain, Chrohn's Disease, Nausea, Ulcers)
Endocrine: (ex. Diabetes, Hypothyroid, Hyperthyroid)
Allergic/Immune: (ex. Hives, Itching, Sneezing, Swelling)
Blood/Lymph: (ex. Anemia, Easy Bruising, Nosebleeds, Shortness of Breath)


Patient / Family Medical History

Do you have a history of these conditions?

Diabetes
YrDx HbA1C
HTN
High Chol
Thyroid
Cardiovascular
Cancer


Does your Family have a history of these conditions? Unknown Family History

Diabetes
HTN
High Chol
Thyroid
Cardiovascular
Cancer


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:

COVID Questionnaire

A. Over The Past 14 Days, Have You Had Any Of these Symptoms?

1. Fever or chills
2. Dry Cough
3. Shortness of breath
4. Muscle or body aches
5. Sore throat
6. New loss of smell and/or taste
7. Headache (influenza like illness)
8. Fatigue (influenza like illness)
9. Nausea or Vomiting
10. Diarrhea
11. Have you had close contact with anyone who has COVID-19?
(close contact is defined as 10 minutes)
12. Have you traveled in the past 14 days?
13. Have you or anyone in your household been asked to quarantine
or waiting for COVID test result?