All fields marked with
*
are required
Patient Information
General Information
Title
Mr.
Mrs.
Ms.
Dr.
Rev.
First
*
MI
Last
*
Nickname
SSN
Contact Information
Home Phone
Cell Phone
Work Phone
Other Phone
Email
*
Preferred Contact Method
Home Phone
Work Phone
Cell Phone
Other Phone
Text Message
Email
Primary Address
Address
*
City
*
State
*
CA
AK
AL
AR
AZ
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
*
Billing address is different
Billing Address
Address
City
State
CA
AK
AL
AR
AZ
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip
Demographics
Birthday (mm/dd/yyyy)
*
Marital Status
Annulled
Divorced
Domestic partner
Interlocutory
Legally Separated
Married
Never Married
Polygamous
Widowed
Sex
*
Male
Female
Occupation
Occupation
*
Employer / School Name
Employment Status
Employed
F/T Student
P/T Student
Other
Other information, (Ex: Guardian name)
Emergency Contact Name
*
Emergency Contact Phone
*
Are you experiencing or have been diagnosed with any of the following?
General
*
None
Fatigue
Fever
Weight Gain
Weight Loss
Other
Illness or pain
*
None
Dry throat / mouth
Headache
Sleep apnea
Arthritis
Other
Cardiovascular conditions
*
None
Heart disease
High Cholesterol
Hypertension
Stroke
Other
Respiratory conditions
*
None
Asthma
Emphysema
Chronic cough
Other
Mental disorders
*
None
Anxiety
Bipolar
Depression
Other
Endocrine system disorders
*
None
Diabetes
Hypothyroid
Hyperthoyroid
Other
Urinary conditions
*
None
Painful urination
Blood in urine
Other
Muscular system disorders
*
None
Pain/tenderness
Weakness
Other
Digestive system conditions
*
None
Acid reflux
Inflammatory Bowel Syndrome
Other
Skin conditions
*
None
Psoriasis
Rosacea
Allergic dermatitis
Other
Nervous system conditions
*
None
Memory problems
Numbness, paralysis
Tremors
Other
Reproductive system disorders
*
None
Breast cancer
Prostate cancer
Ovarian cancer
Other
Blood / Lymphatic disorders
*
None
Anemia
History of blood loss
Cuts slow to clot
Other
Habits
Do you smoke?
Please select
Never smoker
Former smoker
Current occasional smoker
Light smoker (less than 10 cigs/day)
Heavy smoker (more than 10 cigs/day)
Do you drink alcohold daily?
Please select
No
Yes
Do you use recreational drugs?
Please select
No
Yes
Please list ALL medications you are taking
*
type none, if not taking any medications
Are you allergic to any medications?
*
type none, if don't have any allergies to medications
Primary care physician?
Name/City/Medical Center:
How long ago last visited?
Please select
1 week
1 month
3 months
6 months
1 year
2 years
Greater than 3 years
Previous eye doctor
Name/City/Medical Center:
How long ago last exam?
Please select
1 week
1 month
3 months
6 months
1 year
2 years
Greater than 3 years
Family history
*
Glaucoma
No
Parents
Sibling
Grandparents
Other
Cataracts
No
Parents
Sibling
Grandparents
Other
Macular Degeneration
No
Parents
Sibling
Grandparents
Other
Retinal Detachment
No
Parents
Sibling
Grandparents
Other
Other eye diseases
Have you ever been diagnosed or had any of the following?
Glaucoma
Cataracts
Amblyopia
Macular Degeneration
Eye Turn
Retinal Detachment
Keratoconus
Eye surgery
Other
Vision correction
Primary vision correction
Please select
Glasses
Contacts lenses
Other
None
Type of contact lenses, if any
Please select
Soft
RGP lenses
Scleral
CRT
Other
Referral Information
How did you hear about us?:
Yelp
Google
Friend/Family Referral
Insurance Referral
Nextdoor.com
Other
If other or friend/family referral, who?:
Submit