Online Patient Form

Patient Information and Medical History

Thank you for using our secure online forms. Please fill out as much information as you can. When you are finished be sure to hit the submit button at the bottom of the Detailed History tab. If you have any questions, please call us at 541-342-3100. We can always change the data in the office if you are unsure about what to enter in any of the fields.

Patient Information

Patient Demographics

*required (first and last name and either a home OR cell phone)

Title	First*	Last*	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev. Fr.

Address
City	St NC AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY ND OH OK OR PA RI SC SD TN TX UT VT VI VA WA WV WI WY	Zip

Hm Phone*
Cell Phone*
Wk Phone
Other Phone
Email
Preferred Contact By	Cell Phone Home Phone Work Phone Other Phone Text Message Email
DOB (mm/dd/yyyy)
Sex	Female Male
Marital Status	Annulled Divorced Domestic Partner Interlocutory Legally Separated Married Never Married Polygamous Widowed
Employment Status	Employed FT Student PT Student
Occupation/Grade
Employer/School
Parent/Guardian/Phone
Family members with Lifetime Eye Care
Race	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Patient Declined to Specify
Ethnicity	Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify
Preferred Language	English Spanish

Who may we thank for referring you to our office?  

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Fr.

Address
City	St NC AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY ND OH OK OR PA RI SC SD TN TX UT VT VI VA WA WV WI WY	Zip
Hm Phone
Wk Phone

General Medical History

General Medical History

Primary physician's name and phone
When was your last physical exam?

Check the box for any conditions that apply:

	You	Mom	Dad	Sib	None	Describe (type, when were you diagnosed, etc)
Hypertension
Thyroid
Cardiovascular
Cancer
Diabetes

If YOU are diabetic, when were you diagnosed?		Last A1C level?
Are you Pregnant or Nursing?   No Unsure Pregnant Nursing

List ALL major injuries or surgeries you have had and approx dates (e.g. brain injury, concussion, whiplash, etc):

List any other medical conditions you have had, including non-drug allergies (e.g. autism, developmental delays, etc):

List all Rx and over-the-counter medications you currently take:

List any vitamins or supplements you currently take:

List any drug allergies you have:

Smoking Status	Never smoker (<100 cigs equiv) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Current every day smoker Unknown if ever smoked
Alcohol Use	No Yes Occasionally Socially 1 drink per day Multiple drinks per day
Do you live alone?	No Yes assisted living nursing home

Review of Systems

Please list any problems you are currently having anywhere, from head to toe:

General (e.g., fever, fatigue, loss of appetite, unexplained weight loss/gain)

Ear, Nose, Throat (e.g., sinus/nasal congestion, nose bleeds, dry mouth/throat, sleep apnea, hearing problems)

Cardiovascular (e.g., chest pain, racing heartbeat, swollen feet/ankles, TIAs)

Respiratory (e.g., chronic cough, shortness of breath, wheezing)

Genital, Kidney, Bladder (e.g., bladder/urinary problems, pain, discharge, menstrual changes, impotence)

Gastrointestinal (e.g., constipation, diarrhea, gastric reflux (GERD), jaundice, nausea, vomiting)

Endocrine (e.g., heat or cold intolerance, thinning hair, excess thirst, excess urination)

Muscles, Bones, Joints (e.g., pain, stiffness, swelling, weakness, limited movements)

Skin (e.g., dry, rash, growths, rosacea, MRSA infection)

Neurological (e.g., headaches, numbness/tingling, tremors, poor balance, dementia, speech problems)

Psychiatric (e.g., depression, anxiety, sleep problems, paranoia, obsessive/compulsive)

Blood/Lymph (e.g., anemia, bleeding gums, delayed clotting, unexplained bruising)

Allergy/Immune (e.g., swollen lymph nodes, itching, sneezing, runny nose/eyes)

Ocular History

Who was your previous eye doctor?
When was your last eye exam?

Check the box for any conditions that apply:

	You	Mom	Dad	Sib	None	For YOU describe (type, when you were diagnosed, which eye(s), treatment,etc)
Glaucoma
Macular Degeneration
Retinal problems
Cataracts
Lazy Eye/Eye Turn

List any major eye injuries, infections or surgeries and approx dates:

List any other significant eye problems you have had:

List all Rx and over-the-counter eye medications you currently use:

List any vision complaints you are currently having such as: blurred vision, headaches, eyestrain, double vision, loss of vision, dizziness or losing your place when reading itching, burning, redness, pain, sensitivity to light, watering, crusting or mucus discharge seeing rainbows around white lights at night, flashes of light or dark spots/squiggles/webs

How many hours/day do you typically spend using a computer or other digital devices?
If you are having complaints with computer work, how far is the monitor from your eyes?
How many hours/day do you typically spend reading books, magazines, etc?

What are your hobbies/sports activities?
Do you have sunglasses?
Do you have back-up glassess?
Are you interested in contacts?
Contact Lens Wearers Only
What disinfecting solution do you use?
How long do you usually wear your lenses?
How often do you replace your lenses?
How old is your current pair of contacts?

*** Please open the Detailed History tab, complete any section which applies to you and click the SUBMIT button to send your data. Thank you! ***

Detailed History

Please choose from the menu options or select "OTHER" to type your answer. Thank you!

Additional History Forms

Please complete any of the following that apply to you:

PEDIATRIC HISTORY	SCHOOL RELATED HISTORY
READING / COMPUTER SYMPTOM CHECKLIST	BRAIN INJURY HISTORY
DIZZINESS / MOTION SENSITIVITY CHECKLIST	SPORTS VISION HISTORY

Pediatric History

Birth Complications involving prematurity, NICU, forceps, fetal drug or alcohol exposure, etc.:

Special Circumstances such as adoption (age), foster child, developmental concerns, etc.:

Creeped at age:

Walked at age:

Unusual motor development:

Dominant hand for:	Eating	Right Left Other	Throwing	Right Left Other	Hammering	Right Left Other	Writing	Right Left Other
Dominant hand for:	Hopping	Right Left Other	Kicking	Right Left Other	Toe drawing	Right Left Other

Performance compared to peers:

Early speech clear?

Yes No Other

Current speech clear?

Yes No Other

Did your child require any special developmental testing?

None reported Auditory Processing Hearing Speech / Language Motor Educational Psychological Neurological Other/Multiple tests (please fill in which)

School Related History

Grade

School

Age at entrance into:

Preschool:

Kindergarten:

First Grade:

Regular attendance?

Yes No Other

Grade repeated?

No Yes Other

Which?

Describe special classes, tutoring, IEP:

Academic performance:

Above Average Average Below Average Mixed Other

Working harder than expected based on potential:

No Yes Other

Easier subjects:
Harder subjects:

Difficulty learning to read?	Yes No Other	Reading comfortable and efficient?	No Yes Other	Enjoys reading?	Yes No Other
Prefers to be read to:	Yes No Other	Learning difficulty:	Yes No Other

Reading / Computer Symptom Checklist:

Eye fatigue

Eye discomfort

Headache

Feel sleepy when reading

Loose concentration

Trouble remembering what was read

Double vision

Words move on the page

Read slowly

Experience a pulling feeling around eyes

Words blur out of focus

Loss of place

Re-read lines

Close one eye

Head Movement

Poor comprehension

Head too close to paper

Difficulty tracking moving objects

Writing is crooked or poorly spaced

Misaligns digits or columns

Errors copying

Avoid near work

Difficulty completing work in allotted time

Reverse letters, numbers or words

Confuse similar looking words

Fail to recognize the same word in the next sentence

Poor spelling

Confuse right and left

Difficulty with sequences of directions

Whispers when reading silently

Comprehension decreases over time

Brain Injury History

Date of the event (accident, illness, injury, stroke, etc.):

Briefly describe the brain injury (stroke, head trauma, right or left brain injury, whiplash, concussion, accident, etc.)

Describe any previous brain injury and date

What rehabilitation therapy have you received for this injury?

What are your most significant vision concerns at this time?

Please check if any symptoms below are present from before or only after the injury:

Before	After
	Pain in or around eyes
	Visual headache
	Decreased blink rate
	Distorted vision
	Tendency to stare
	Frequent squinting or excessive blinking
	Unusual head tilt or head turn
	Difficulty understanding what is seen
	Difficulty recognizing words
	Difficulty recognizing faces
	Difficulty finding objects when grouped together
	Memory problems
	Difficulty reading (complete READING / COMPUTER SYMPTOM CHECKLIST)
	Dizziness or motion sickness (Complete DIZZINESS / MOTION SENSITIVITY CHECKLIST)
	Difficulty focusing one or both eyes
	Tendency to close one eye to see clearly
	Vision appears unstable or shifts from eye to eye
	Difficulty judging depth
	Portions of a page or objects appear to be missing
	People or things suddenly appear unexpectedly from one side
	Looking to the side of objects to see them better
	Tunnel vision
	Difficulty concentrating on visual tasks
	Discomfort in crowded areas with a lot of background motion
	Difficulty maintaining eye contact

Dizziness / Motion Sensitivity Checklist

Nausea or dizziness when reading in the car even on a STRAIGHT road

Nausea or dizziness when sitting close to a movie or watching motion

Nausea or dizziness when shopping or moving through crowds of people

Busy background patterns or background movement bothers you

Hyper-sensitive to light (outside, store lights, tend to wear sunglasses even on cloudy days)

Flickering lights bother you (light through trees)

Unusual fear of heights

Sports Vision History

Do you wear prescription while playing your sport (glasses or contact lenses)?

Do you ever experience blur or double vision? Under what conditions / at what distance / during your sport?

How is your game? How would you like to improve? Can you present specific examples?

How would you describe the consistency of your game? Does your performance deteriorate as the game goes on? Are there big differences in your game from day to day? Is there a difference in your performance from day to night? Or a difference during a tournament?

Do you feel your vision interferes with your game? If so, can you describe specific examples?

How is your ability to keep your eye on the ball? (Or other moving target / object) Please give an example

Is there a fluctuation in your vision when looking from one spot to another or when you are moving?

How would you describe your performance in critical situations under stress?

How do you feel vision is important in your sport?

Do you use visualization / imagery techniques? If yes, please describe. Would you like to further develop this skill?

Have you ever suffered a head injury, been hit in the head, or incurred a concussion or whiplash?

Please click the submit button to complete your online forms. Thank you!