Online Patient History Form

After completing the form, please click the Submit button at the bottom of the page.

Patient Information

City: State: Zip Code:
Home Phone*: Work Phone:
Cell Phone*: Preferred Contact Method:
SSN (Last 4) Email
Birthday* Age Marital Status
Sex New or Established Patient:
Are you currently employed?: Are you currently in school?:

Billing Information

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

Medical Insurance

Do you have medical insurance?*:

Vision Plan

Do you have vision insurance?*:

Medical History

Reason for Visit

Please check all that apply:

Are you interested in LASIK Surgery?:
Do you have any specific questions or problems
you would like to discuss with your doctor?:

Last Eye Doctor: Last Eye Exam:

Personal Eye History

Do you currently wear glasses?:
Do you currently wear sunglasses with UV protection?:
Do you wear contact lenses?:
Do you experience seasonal allergies that affect your eyes?:
Have you ever had LASIK or refractive surgery?:
Have you ever had eye surgery?:

Do you currently experience:

Please check all that apply:

Computer Vision History

Do you use a computer for personal or business use?:

Review of Systems

Do you currently have, or have you ever had any serious problems in the following areas?
Please check all that apply:

General Diabetes:
High Blood Pressure: Neurological:
Gastrointestinal: Skin:
Allergy/Immune: Cardiovascular:
Endocrine: Musculoskeletal:
Respiratory: Blood/Lymph:
Mental: Ear/Nose/Throat:
Cancer: Genitourinary:

Are you currently under the care of a physician for any
ACUTE (short-lasting) condition not listed above?:

Are you currently under the care of a physician for any
CHRONIC (long-lasting) condition not listed above?:

Medical History

Primary Care Physician: Last Medical Exam:

Are you allergic to any medications?:

Are you pregnant?:
Are you nursing?:

Current Medications

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

Please list all eye medications you are currently using:

Social History

Do you drive?:

Do you use tobacco products?:
Do you drink alcohol?:
Do you participate in any sports?:

Family History

Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions.
Please check all that apply:

Disease/Condition Relationship to You

How did you hear about us?:

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