Online Patient Form

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Demographics


Patient Information
Title First Last MI Suffix Nickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name
Misc/Guardian



Medical History


Last Eye Exam:

Primary Care Physician: Last Physical Exam:

Eye History

Do you currently have any of the following symptoms?

  No Yes Additional Notes
Blurred Vision
Eye Pain
Eye Redness
Foreign Body Sensation
Discharge
Flashes/Floaters
Burning
Itching
Diplopia

Do you have a history of any of the following?

  No Yes Additional Notes
Eye Surgeries
Eye Injuries
Cataract(s)
Color Blindness
Glaucoma
Macular Degeneration
Retinal Detachment
Strabismus
Other

Review of Systems

Do you currently have any of the following?

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

Currently pregnant or nursing?:

Medical History

Please list any surgeries:

Family History

Has anyone in your family ever had any of the following?

  Additional Notes
Glaucoma
Macular Degeneration
Cataract(s)
Diabetes
High Blood Pressure
Heart Disease

Social History

Do you drink alcohol? How much per day/week?
Do you smoke? How much per day/week?
If a previous smoker, when did you quit?

Do you drive? Visual difficulty with driving?
Do you use a computer? Hours per day on computer:

Sports/Hobbies:

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Patient Signature Forms

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