Online Patient Form

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Patient Information


TitleFirstLastMISuffixNickname
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Cell Phone: Preferred Contact Method:
SSN (last 4) Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name
New or Established Patient:

Emergency Contact

Name: Phone Number:

Billing Information

Is The Billing Address the Same?
TitleFirstLastMISuffix
Address:
City: State: Zip Code:
Home Phone:
Work Phone:

Medical Insurance

Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account:

Vision Plan

Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account:

Medical History

Reason for Visit: Secondary Reasons:

Eye History

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:
Have you had any eye surgeries? Please describe:
Last Eye Exam: By Doctor:

Primary Vision Correction:
Do you:    Have back up glasses? Want new glasses? Want backup sunglasses?:

Are you experiencing any vision problems with your glasses?:
 (Please check all that apply:)
 
 
 
 
Do you have problems with glare/reflections (especially when driving at night)?:

Contact Lens Wearers only
Type of contacts worn in the past: Cleaner: Disposal:
Wear Time:

Are you experiencing any vision problems with your contact lenses?:
 (Please check all that apply:)
 
 
 
 

Family Eye History

Macular Degen:
Glaucoma:
Retinal Detach:
Cataracts:
Lazy/Crossed Eye:
Blindness:

Computer Vision History

Do you use a computer for personal or business use?: No

Review of Systems

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

Medical History

Please describe any injuries or surgeries you have had:

Primary Care Physician: Last Visit: Reason:
Pregnant Or Nursing:


Do you have any of these medical conditions? If yes, please describe:

Diabetes: Year Diagnosed:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:

Family Medical History



Does anyone in your family have any of these medical conditions? If yes, please describe:

Diabetes:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Other:

Current Medications

(Prescription medications and over the counter)
Please check all that apply:


Please list medications:


Over The Counter Medications:
Vitamins: Drug Allergies:

Social History

Do you drive?: No


Hobbies:

Smoking Status: Type: How Long:
Alcohol Use: Type: How Long:
Illegal Drug Use: Type: How Long

Race: Ethnicity: Preferred Language:

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