Online Patient Form

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Please submit your data on the Submit Data tab by clicking on the "Submit Data" button.

** All items under the Medical History tab must be filled out, use "None" if the item doesn't apply. **

Demographics


Patient Information
TitleFirstLastMISuffixPreferred Name
Address:
City: State/ZipCode
Cell Phone: Work Phone:
Other Phone:
Home Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Birth Gender Employment Status
Marital Status Employer / School Name
Misc/GuardianDrivers License #
Race:
Ethnicity:



Vision Insurance

Please take a picture of the front and back of your insurance cards and
text them to 540-953-2020 or email them to us at frontdesk@blacksburgeye.com

Medical Insurance

Please take a picture of the front and back of your insurance cards and
text them to 540-953-2020 or email them to us at frontdesk@blacksburgeye.com

Medical History

PATIENT MEDICAL HISTORY

Reason for your visit:
Other concerns with your vision or eyes:
List all allergies including medications

List all prescription medications you are currently taking (including eyedrops):
Smoking Status: How Long: Type:
Alcohol Use: Amount / Frequency:

Height
Ft In
Weight (approximate)
Lbs

General Health:
Ear, Nose & Throat:
Cardiovascular:
Respiratory:
Genitourinary:
Musculoskeletal:
Gastrointestinal:
Skin:
Neurological:
Psychiatric:
Endocrine:
Blood/Lymph:
Allergy/Immune:
Infectious Disease:

FAMILY HISTORY

Diabetes:
Hypertension:
Thyroid:
High Cholesterol:
Cancer:
Cardiovascular:
Other:

FAMILY OCULAR HISTORY

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

OCULAR HISTORY

Please list any history of ocular injury or previous diagnoses

Please list any history of ocular diseases or previous diagnoses:

Other Medical History

Please list other surgeries, hospitalizations, or significant injuries (including concussion):

OTHER INFORMATION

Pregnant or Nursing:

Preferred Pharmacy:
Pharmacy Location:

PRIMARY CARE INFORMATION

Primary Care Physician: Last Visit: Reason:

List all OTC supplements and/or vitamins you are currently taking:
List all OTC medications you are currently taking (including eyedrops):


Last Eye Doctor: Last Visit: Reason:

Primary Vision Correction:
Types of Contact Lenses worn in the past:
Disposal:
Wear Time:
Current Contact Lens Brand and Power:
Do you sleep in your contact lenses?:



PATIENT ACKNOWLEDGEMENT

**BE SURE ALL FIELDS ON THIS TAB ARE COMPLETED! If this question doesn't apply to you be sure to put "None" or NA" in the field.**

By typing your name below you acknowledge the information entered above is true and correct to the best of your knowledge
Date:

Submit Data