Online Patient Form

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Patient Information and Medical History Form

Thank you for using our secure online form. 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 form. If you have
any questions, please call us at 702-634-2020 (Seven Hills) or 702-871-3937 (the District).
We can always change the data in the office if you are unsure about what to enter in any of the field.


TitleFirstLastMISuffixNickname
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation/Grade:
Sex Employment Status
Marital Status Employer / School Name
Misc/Guardian
Who may we thank for referring you to our office?:

Billing Information

Is The Billing Address the Same?
TitleFirstLastMISuffix
Address:
City: State: Zip Code:
Home Phone:
Work Phone:

Insurance Information

Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Are you the primary insurance holder?:
Primary on Account (Please fill out if you answered 'No' above)
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

Eye History

Do you have a history of any of these eye conditions?

    Yes    No
Glaucoma     
Macular Degeneration     
Retinal Conditions     
Cataracts     
Blindness     
Crossed Eyes     
Lazy Eye     
Color Blindness     
Double Vision     
Serious Eye Infection     
Flashes/Floaters     

Other Eye Conditions? If so, please describe:
Have you had any eye surgeries? If so, please describe:
Have you had any eye injuries? If so, please describe:

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

How many hours/day do you typically spend using a computer or other digital devices?:
How many hours/day do you spend driving?:
How many hours/day do you spend reading books, magazines, etc.?:

Do you have sunglasses?:
Do you have back-up glasses?:
Are you interested in contacts?:

Contact Lens Wearers Only

What disinfecting solution do you use?:
How many hours/day do you wear contacts?:
How many days/week do you wear contacts?:
How often do you replace your contacts?:
How old is your current pair of contacts?:

Medical History

Do you have a history of any of these conditions?

    Yes    No    Describe
Diabetes            A1c:
High BP         
High Cholesterol         
Thyroid Conditions         
Heart Conditions         
Cancer         
Arthritis         
Asthma         
Migraines         

Other Medical Conditions? If so, please describe:

Do you take any medications? If so, please list:
Are you allergic to any medications? If so, please describe:

Primary Care Physician:

Are you Pregnant or Nursing?:

Family Eye History

Does your family have a history of any of these eye conditions?

    Mom    Dad    Sibling    Paternal
  Grandma
   Paternal
   Grandpa
   Maternal
   Grandma
   Maternal
   Grandpa
   None
Glaucoma                                                   
Macular Degeneration                                                   
Retinal Conditions                                                   
Cataracts                                                   
Lazy/Cross Eye                                                   
Blindness                                                   

Other Family Eye Conditions? If so, please describe:

Family Medical History

Does your family have a history of any of these conditions?

    Mom    Dad    Sibling    Paternal
  Grandma
   Paternal
   Grandpa
   Maternal
   Grandma
   Maternal
   Grandpa
   None
Diabetes                                                   
High BP                                                   
Thyroid Conditions                                                   
Heart Conditions                                                   
Cancer                                                   

Other Family Medical Conditions? If so, please describe:

Review of Systems
Allergy/Immune:
Musculoskeletal:
Cardiovascular:
Current:
Ears, Nose, Throat:
Endocrine:
Gastrointestinal:
Genitourinary:
Skin:
Blood/Lymph:
Neurological:
Psychiatric:
Respiratory:
Cancer:

Social History
Race: Ethnicity: Preferred Language:

Smoking Status: Alcohol Use:

What are your hobbies/sports activities?:

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