Online Patient Forms

Announcement: Battle Born Eye Care is now pleased to offer digital retinal imaging as part of our comprehensive eye exams. We believe the combination of dilation and retinal imaging allows for the best of all worlds: a real time view of the posterior structures of the eye combined with a digital image that provides easy comparison of the ocular structures from year to year. The fee for the digital retinal imaging is $39.

Patient information

First name

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Last name

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Birth Sex

Male Female

Address

Apt/Suite #

City

State

Zip Code

Cell Phone

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Home Phone

Preferred Contact Method

Birthday

Last 4 of SSN

Occupation

Employer/School Name

Marital Status

Misc/Guardian

Authorized persons to release medical information to:

Is there a certain way you would like to be addressed by our clinic? (Example: Nicknames, preferred pronouns, etc.)

Billing information

Is The Billing Address Different? Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

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Medical History

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Eye History

Reason for Visit

Primary Reason

Secondary Reason

Do you currently have any of these symptoms?

Do you currently take any of these EYE medications?

Have you had any eye surgeries? Please describe

Last Eye Exam Date

Last Appointment Type

Doctor

Primary Vision Correction

Do you:

Have Backup Glasses?

Want New Glasses?

Contact Lens Wearers only:

Name of Contacts you currently wear

Cleaner

Disposal

Wear Time

Medical History:

Medications No 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

Recent Flu Immunization

Do you have any of these medical conditions?

Diabetes

Year Diabetes diagnosed if applicable

Hypertension

High Cholesterol

Thyroid Conditions

Heart Conditions

Cancer

Other

Family Medical History

Unknown family history

Does anyone in your family have any of these medical conditions?

High Blood Pressure

Diabetes

Thyroid

Cancer

High Cholesterol

Heart Conditions

Other

Family Eye History

Does anyone in your family have any of these eye conditions?

Unknown family eye history

Macular Degeneration

Glaucoma

Retinal Detachment

Blindness

Cataracts

Lazy/Crossed Eye

Review Of Systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Social History

Hobbies

Smoking Status

Type

How long

Alcohol Use

Type

How long

Recreational Drug Use

Type

How long

Race

Ethnicity

Preferred Language

Neurolens Lifestyle Index

This questionnaire is meant to help your doctor understand what you're experiencing on a regular basis - whether it's caused by your eyes, posture, stress, etc. Your responses will help make sure you receive the best care possible.

How often do you experience any of these symptoms?

Scale: 1-Never, 2-Rarely, 3-Sometimes, 4-Very often, 5-Always

Headaches: (of any severity each week, usually getting worse later in the day)

Stiffness / pain in neck / shoulders (when you work at a computer or read)

Discomfort with Computer Use (in your eyes (redness, burning) after long hours looking at the screen)

Tired Eyes (with increasing feeling of eye fatigue throughout the day)

Dry Eye Sensation (feeling progressively more gritty/sandy while working at computer or reading)

Light Sensitivity (especially with brighter, stronger lights like fluorescents or headlights)

Dizziness (or an experience like motion sickness or vertigo)

Contact Lens Satisfaction Survery (only for current contact lens wearers)

Scale: 1-Awful...10-Amazing

How would you rate the comfort of your contacts at the beginning of the day?

How would you rate the comfort of your contacts at the end of the day?

How often do you have to use rewetting drops/artificial tears while wearing your contacts?