Online Patient Form

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Demographics


TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
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
Primary Doctor Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Primary Insurance Information

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:

Secondary Insurance Information

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:

Tertiary Insurance Information

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:   Other Reasons:
  

Last Worn Contact Lenses: Interested in contacts?:

Last Exam: Which Office?: By Doctor:


Glasses History

I don't have a prescription
I lost my glasses
I broke my glasses
I didn't bring my glasses


Your Eye History                                                                                                                    Your Medical History

Glaucoma: Yes No                                                                                                  Diabetes: Yes No    Year Diagnosed: A1c:
Macular Degen: Yes No High BP: Yes No
Retinal Disease: Yes No High Cholesterol: Yes No
Cataracts: Yes No Heart Disease: Yes No
Lazy Eye: Yes No Thyroid: Yes No
Vision Loss: Yes No Cancer: Yes No
Crossed Eyes: Yes No Arthritis: Yes No
Dry Eyes: Yes No Asthma: Yes No
Color Blindness: Yes No Migraines: Yes No
Double Vision: Yes No
Eye Infections: Yes No
Flashes/Floaters: Yes No

Other Eye Conditions:                                                                                       Other Medical Conditions:
                                                                                      
Eye Surgeries:                                                                                       Medications:
                                                                                      
Eye Injuries:                                                                                       Drug Allergies:
                                                                                      

Primary Care Physician:


Family History Unknown

Family Eye History
   None    Mom    Dad    Sibling     Paternal
   Grandma
    Paternal
    Grandpa
   Maternal
   Grandma
   Maternal
   Grandpa
Glaucoma:                                                    
Macular Degen:                                                    
Retinal Detach:                                                    
Cataracts:                                                    
Lazy/Crossed Eye:                                                    
Blindness:                                                    

Other Family Eye Conditions:


Family Medical History
   None    Mom    Dad    Sibling     Paternal
   Grandma
    Paternal
    Grandpa
   Maternal
   Grandma
   Maternal
   Grandpa
Diabetes:                                                      
High BP:                                                      
Thyroid Disease:                                                      
Heart Disease:                                                      
Cancer:                                                      

Other Family Medical Conditions:


Review of Systems

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


Social History

Race:      
Hobbies: Computer Use:

Smoking Status: Alcohol Use: Illegal Drug Use:

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