Round Rock Family Eyecare

Online Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Primary Doctor Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Chief Complaint


CHIEF COMPLAINT

Length
Onset
Remedy
Intensity
Duration
Association

Secondary Complaints
PATIENT OCULAR HISTORY: Injuries, Infections, Surgeries, Diseases, Binocular complaints
Eye Meds:
Last Eye Exam:
Doctor:
Glaucoma
Cataracts
Macular Degen
Retinal Detach
Crossed / Lazy
Glasses:
Previous Contacts used:
Dispose:
Solutions:
NOTES:

Medical History


**PLEASE COMPLETE ALL APPLICABLE FIELDS**

PRIMARY CARE PHYSICIAN:  Last Visit:  Reason For Visit: 

Drug Allergies:  OTC:   Vitamins: 

Current Medications:


PATIENT MEDICAL HISTORY: HAs, Arthritis, Asthma, Diabetes, HBP, Heart, Infl. Bowel Disease, Seizures, Thyroid:
     

Injuries, Surgeries, Hospitalization: 

Pregnant or Nursing: 

FAMILY MEDICAL HISTORY: Diabetes, HBP, Heart Disease, Cancer, Athritis, Lupus, Kidney, Thyroid, Other:
          

SOCIAL HISTORY

Occupation:  Employer: 

Tobacco:        Hobbies: 

  Alcohol:   Illegal Drugs: 

DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?

GENERAL: Fever, weight loss, weight gain, fatigue? 

EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat 

CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease 

RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD 

GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence 

MUSCLES, BONES, JOINTS: Athritis, Joint Pains, Head or Neck Injury 

SKIN: growths, rashes, acne 

NEUROLOGICAL: Headaches, migraines, seizures 

PSYCHIATRIC: Depression, Anxiety, Insomnia 

ENDOCRINE: Thyroid, Diabetes 

ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus 

GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux 

     BLOOD/LYMPH: Anemia, cholesterol, bleeding problems 

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