Online Patient Form

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Patient Information

City: State: Zip Code:
Cell Phone: Home Phone:
Preferred Contact Method:
Birthday Sex
Occupation Employer / School Name

Medical History

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Eye History

Reason for Visit: Secondary Reasons:

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:
Last Eye Exam: By Doctor:

Primary Vision Correction: Back up specs?

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

Medical History

Over The Counter Medications:
Please describe any injuries or surgeries you have had:

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

Family Medical History

Family Medical History (Adopted, Diabetes, High Bloop Pressure, Cancer, Lupus, Thyroid, Cardiovascular Disease etc)

Family Eye History

Does anyone in your family have any of these eye conditions?:

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

Review of Systems

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

Social History


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

Race: Ethnicity: Preferred Language:

Recommended Diagnostic Tests

As your eye care professional, I strongly recommend that all patients receive a dilated examination as part of a comprehensive evaluation. This allows for a better view of the inside of your eyes, to look for conditions such as retinal tears/detachments, diabetic complications, tumors, and much more. Without dilation, it is possible to overlook potential vision- or life-threatening conditions. After the dilated examination, you may experience blurred vision and light sensitivity for four (4) to six (6) hours (and possibly longer in rare cases). This could potentially impact your ability to drive or perform certain visual tasks.

Yes, I consent to dilation today (included in exam)

I would like to reschedule my dilation and I will be responsible for rescheduling

No, I decline dilation. I understand the risks of an examination without dilation.

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