Online Patient Form

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After completing all the forms, please submit your data using the button at the bottom of the page. Thank you!

Items marked with * are required.

Patient Information

Title	First*	Last*	MI	Suffix	Nickname

Address:*

City:*	State:*	Zip Code:*

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
		Emergency Contact Name / Phone Number:

Billing Information

Is The Billing Address the Same? Yes

Title	First*	Last*	MI	Suffix

Address:*

City:*	State:*	Zip Code:*
Home Phone:*
Work Phone:

Medical History

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

Do you wear sunglasses?:	Yes	No
Do you use a computer?:	Yes	No -	Desk	Lap -	Hours Per Day:

Eye strain, neck ache, glare, other discomfort with computer use?:

Yes

Ocular Surgeries*

Surgeries	Surgery Dates	Surgeon

Ocular Medications*

Ocular Medications	Amount	Eye	Dosage

Medications*

Medications

Drug Allergies*

Drug Allergies

Surgeries*

Surgeries	Surgery Dates

Eye History

Glaucoma*	Yes	No
Macular Degen*	Yes	No
Cornea*	Yes	No
Retina*	Yes	No
Lazy Eye*	Yes	No
Crossed Eyes*	Yes	No
Lid Infection*	Yes	No
Blindness*	Yes	No
Color Blindness*	Yes	No
Tumors*	Yes	No
High Risk Medications*	Yes	No
Other*	Yes	No

Family Eye History

Glaucoma*	Yes	No
Macular Degen*	Yes	No
Cornea*	Yes	No
Retina*	Yes	No
Lazy Eye*	Yes	No
Crossed Eyes*	Yes	No
Lid Infection*	Yes	No
Blindness*	Yes	No
Color Blindness*	Yes	No
Tumors*	Yes	No
High Risk Medications*	Yes	No
Other*	Yes	No

Review of Systems

Ear/Nose/Throat*	Yes	No
Blood/Lymph*	Yes	No
Genital/Kidney/Bladder*	Yes	No
Cardiovascular*	Yes	No
Respiratory*	Yes	No
Gastrointestinal*	Yes	No
Endocrine*	Yes	No
Neurological*	Yes	No
Muscles, Joints*	Yes	No
Psychiatric*	Yes	No

Family Review of Systems

Ear/Nose/Throat*	Yes	No
Blood/Lymph*	Yes	No
Genital/Kidney/Bladder*	Yes	No
Cardiovascular*	Yes	No
Respiratory*	Yes	No
Gastrointestinal*	Yes	No
Endocrine*	Yes	No
Neurological*	Yes	No
Muscles, Joints*	Yes	No
Psychiatric*	Yes	No

Health Info

Primary Care Physician:		Last Physical:
Pregnant/Nursing:*

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

Race:
Ethnicity:
Preferred Language:

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