Online Patient Form

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Patient Information

City: State: Zip Code:
Home Phone: Work Phone:
Other Phone:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name

Billing Information

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

Medical History - Select "Other" to free text

Last Eye Exam - When: Where:

Daily Screen Time - Phone: Tablet: Laptop: Desktop:

Are you using blue light filters for -

Do you use UV eye protection?:

Special Vision/Eyewear Needs:

Have you ever worn prescription glasses?:     How Often?: How Long?:
What are your glasses for?:
Are you happy with them?:       Explain:

Have you ever worn contact lenses?:         How Long:
Type of contacts worn in past:
Prescribed Replacement Schedule:
Actual Replacement Schedule
Cleaning System:
Wearing Schedule: Days per Week: Other:
Have you had a bad reaction to any contacts or solutions?:     Explain:
Are you happy with your current contact lenses?:     Explain:
Do you ever sleep in your contacts?:     How Often: How Many Years:
Last time you wore them: Age of current lenses: Wearing time today:
New Patients - Do you have copy of current contact prescription?:    

Review of Ocular System

Ocular Symptoms

Loss of Vision -
Blurred Vision -
Eyestrain -
Distorted Vision -
Loss of Side Vision -
Double Vision -
Glare/Halos -
Light Sensitivity -
Floaters -
Flashes of Light -
Dark/Blurred Spots -
Dryness -
Mucous Discharge -
Redness -
Sandy/Gritty Feeling -
Itching -
Burning -
Foreign Body Sensation -
Tearing/Watering -
Eye Pain/Soreness -                    

Please select/list any eye conditions you have or have had in the past:
Please list any eye medications or drops you're currently taking:
Please list any other eye related conditions/symptoms:

Family Eye History

Macular Degen: Glaucoma:
Retinal Detach: Cataracts:
Crossed/Lazy: Blindness:
Retinal Disease: Fuch's Dystrophy:
Eye Surgery: Other:

Family Medical History

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

Review of Systems

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

Additional Medical History

Diabetes Type: Year Diagnosed:
Last HA1c: Date:
Last FBS: Date:
Avg BS Range:
Diabetes Doctor:

Cancer: Type:      
Hepatitis:     Type:

Major Injuries, Surgeries, Hospitalizations:

Developmental Disorder or Delay:     Explain:      
Reading or Learning Difficulties:     Explain:
Any problems before, during, or immediately after your birth?:     Explain:

Medications, Allergies, Other History

Please list all of the following that you are currently taking and all medications that you are allergic to:

Over The Counter Medications:
Medication Allergies or Drug Allergies:

Primary Care Physician: Last Visit: Reason For Visit:
Received Flu Immunization?: Recent Tetanus Shot:

Social History

Smoking Status: Type: How Long:
Alcohol Use: Type: How Long:
Recreational Drugs: Type: How Long:
Medical Marijuana:

Preferred Spoken Language: Preferred Written Language:
Do you want a trained professional interpretor?:     (If yes, this requires outside arrangements to be made in advance of your appointment)
If not, what type of interpretor do you wish to use?:     Other:

Race: Ethnicity:

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