Online Patient Form

Click here to return to the the previous website.

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)


Family Medical History

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

Diabetes:  
High BP:
High Chol:
Thyroid:
Heart:
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: