Online Patient Form

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Demographics


Patient Information
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
Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Primary

Insurance Information
Insurance Name:
Insurance Plan:
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 Plan:
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 Plan:
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


Date of Last Eye Exam: Doctor's Name: Location:

I currently wear glasses:   No    Full-time     Part-time     If part-time, how often/when?:

I currently wear contacts: No    Full-time     Part-time     If part-time, how often/when?:

Current Brand: Soft Rigid Gas Permeable
What is your replacement schedule? How old is your current pair?

Are your lenses comfortable? Yes No

Do you have any problems with your contacts? Dryness Redness Itchiness Poor Vision

Do you sleep with your contacts on? Yes No    How often?:

How many hours a day do you use a computer? Describe any visual symptoms from computer use:

Are you currently experiencing any of the following?

   Yes   No
Headaches:        
Blurred Vision:        
Double Vision:        
Hurt/Tired Eyes:        
Floaters:        
Flashing Lights:        
Sandy/Gritty Eyes:        
   Yes   No
Halos around Lights:        
Bothered by Light/Sun:        
Frequent Styes:        
Eyes frequently Red:        
Eyes Itch:        
Eyes Burn:        
Eyes Tear:        
   Yes   No
Gastrointestinal:        
Ears/Nose/Throat:        
Cardiovascular:        
Allergy/Immune:        
Skin:        
Blood/Lymph:        
Muscles/Bones:        
Pregnant/Nursing:        

Have you had any eye surgery? Yes No    If yes, why?

Are you taking any eye medications? If yes, why?

Date of Last Physical: Doctor's name

Are you allergic to any medication?: Yes No    If yes, what?:

Current medication(s):
List any surgeries you have had:
   Self   Family
Blindness:           
Eye Turn:           
Lazy Eye:           
Keratoconus:           
Macular Degeneration:           
Retinal Detachment:           
Glaucoma:           
Cataracts:           
   Self   Family
Neurological:           
Heart Disease:           
Cancer:           
Diabetes:           
Heart Disease:           
High BP:           



Relation to family of any conditions checked: Other eye or medical conditions not mentioned above:

Hobbies:

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