Online Patient Form

Demographics

Patient Information

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

Address:
City:		State/ZipCode	TX 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 NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed	Employer / School Name
Misc/Guardian

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Billing Information

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

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Address

City	State	ZipCode
	TX 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 NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Medical History

Review Of Systems: Do You Currently Have Any Of These Problems?

GENERAL: Fever, weight loss, weight gain, fatigue?	None Negative Fever Weight loss Fatigue Other
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat	None Allergies Sinus Congestion Chronic Cough Dry Throat / Mouth Hard of Hearing Other

CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease	None Hypertension Surgery Vascular Disease Other
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD	None Asthma Bronchitis Emphysema COPD Other
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence	None Painful urination Frequent urination Impotence Yellow jaundice Other
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury	None Joint pain Stiffness Swelling Cramps arthritis Other
SKIN: growths, rashes, acne	None Pimples, warts Growths Rash Other
NEUROLOGICAL: Headaches, migraines, seizures	None Numbness, paralysis Headaches Seizures Migraines Other
PSYCHIATRIC: Depression, Anxiety, Insomnia	None Anxiety Depression Insomnia Other
ENDORCRINE: Thyroid, Diabetes	None hypothyroid hyperthoyroid Diabetes Type I - Controlled Diabetes Type I - Uncontrolled Diabetes Type II - Controlled Diabetes Type II - Uncontrolled Other
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems	None bleeding cholestrolemia anemia Other
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus	None sneezing swelling redness itching hives lupus Other
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux	None Diarrhea Constipation Ulcer Acid Reflux Other

Pregnant Or Nursing:

No Yes Unsure Other

Review of ocular system: injuries, infections, surgeries, diseases

Primary Care Physician	None Other	Endocrinologist/specialist	N/A Other	Other eyecare specialist	N/A Other
Glucometry		Taken
Pharmacy		Emergency contact:

Social History

Occupation:
Smoking Status	Current every day smoker Current some day smoker (not daily) Former smoker (no longer smokes) Heavy smoker (>10 cigs/day) Light smoker (<10 cigs/day) Never smoker (<100 cigs equiv) Smoker (current status unknown) Unknown if ever smoked Other	QTY	<4 per day Half pack/day (12) Pack / day >1 pack/day Other	Duration:	<1 year <5 years <10 years <20 years Other
Alcohol:	No Yes Occasionally Socially Other	QTY	1-2 drinks/week 4-6 drinks/week 6-10 drinks/week >10 drinks/week Other
Recreation Drugs	No Yes Other	Type:	Marijuana Cocaine Muscle Relaxers Heroin Other	Duration:	<1 year <5 years <10 years <20 years Other
STD:	None Gonorrhea Syphilis Hepatitis HIV Herpes Other
Neuro	Oriented Disoriented Other
Psych	Plesant Nervous Agitated Other

Race

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander Other Race Patient Declined to Specify White Other

Ethnicity

Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Other

Preferred Language

English Spanish French Patient Declined to Specify Abkhazian Afar Afrikaans Akan Albanian Amharic Arabic Aragonese Armenian Assamese Avaric Avestan Aymara Azerbaijani Bambara Bashkir Basque Belarusian Bengali Bihari languages Bislama Bokm?l, Norwegian), Norwegian Bokm?l Bosnian Breton Bulgarian Burmese Catalan; Valencian Central Khmer Chamorro Chechen Chichewa; Chewa; Nyanja Chinese Church Slavic; Old Slavonic; Church Slavonic; Old Bulgarian; Old Church Slavonic Chuvash Cornish Corsican Cree Croatian Czech Danish Divehi; Dhivehi; Maldivian Dutch; Flemish Dzongkha Esperanto Estonian Ewe Faroese Fijian Finnish Fulah Gaelic; Scottish Gaelic Galician Ganda Georgian German Greek, Modern (1453-) Guarani Gujarati Haitian; Haitian Creole Hausa Hebrew Herero Hindi Hiri Motu Hungarian Icelandic Ido Igbo Indonesian Interlingua (International Auxiliary Language Association) Interlingue; Occidental Inuktitut Inupiaq Irish Italian Japanese Javanese Kalaallisut; Greenlandic Kannada Kanuri Kashmiri Kazakh Kikuyu; Gikuyu Kinyarwanda Kirghiz; Kyrgyz Komi Kongo Korean Kuanyama; Kwanyama Kurdish Lao Latin Latvian Limburgan; Limburger; Limburgish Lingala Lithuanian Luba-Katanga Luxembourgish; Letzeburgesch Macedonian Malagasy Malay Malay Malayalam Maltese Manx Maori Maori Marathi Marshallese Mongolian Nauru Navajo; Navaho Ndebele, North; North Ndebele Ndebele, South; South Ndebele Ndonga Nepali Northern Sami Norwegian Norwegian Nynorsk; Nynorsk, Norwegian Occitan (post 1500) Ojibwa Oriya Oromo Ossetian; Ossetic Pali Panjabi; Punjabi Persian Polish Portuguese Pushto; Pashto Quechua Romanian; Moldavian), Moldovan Romansh Rundi Russian Samoan Sango Sanskrit Sardinian Serbian Shona Sichuan Yi; Nuosu Sindhi Sinhala; Sinhalese Slovak Slovenian Somali Sotho, Southern Sundanese Swahili Swati Swedish Tagalog Tahitian Tajik Tamil Tatar Telugu Thai Tibetan Tigrinya Tonga (Tonga Islands) Tsonga Tswana Turkish Turkmen Twi Uighur; Uyghur Ukrainian Urdu Uzbek Venda Vietnamese Volap?k Walloon Welsh Western Frisian Wolof Xhosa Yiddish Yoruba Zhuang; Chuang Zulu Other

Family History

Any History Of The Following In Any Family Members (Parents, Grandparents, Siblings, Children)

Condition	Yes	No	Relationship To Patient	Condition	Yes	No	Relationship To Patient
Lazy Eye (Amblyopia)				Diabetes
Blindness				Hypertension
Cataracts				Cancer
Glaucoma				Heart Disease
Retinal Detachment				Autoimmune Disease
Macular Degeneration				High Cholesterol
Retinal Disease				Kidney Disease
Other				Other

Surgeries

Medications

Medications	Allergies
Over The Counter / Vitamins	Ocular Medications / GTTS

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