Online Patient Form

Demographics

Patient Information

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

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:
Cell Phone:		Other Phone:
Email		Preferred Contact:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Occupation
Birthday		Employer/School Name:
Sex	Male Female	Misc/Guardian

Is the Billing Address Different?

Billing Information

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

Copy Address From Above
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:

Vision Insurance

Primary Vision Insurance Information

Insurance Name:	None
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary Vision Insurance Information

Insurance Name:	None
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

Eye History

Do you have any of the following eye issues?:

None Blurred Vision - Distance Blurred Vision - Near Headaches Floaters Burning Flashes of Light Squinting Eye Fatigue Itching Halos Loss of Vision Pain Tearing Redness Excessive Blinking Discharge Dryness Diplopia Crusting Photophobia Swollen Lids Fluctuation of Vision Major Change in Vision Other

Previous Eye Doctor:

Last Eye Exam:

1 year 2 years 3 years Other

Type of contacts worn in the past:	None Disposable Conventional Colored RGP PMMA Cobalt Study Lens Soft Other	What contact solution do you use?:	None PureMoist Optifree Clear Care Boston Renu Biotrue Aquify Other
How often do you dispose of your lenses?:	daily 2 weeks monthly weekly yearly Other	Do you sleep in your contact lenses?:	Yes No Other

Do you or your immediate family currently experience or have a history of any of the following?:

	You	Family	No
Cataract(s)
Lazy Eye
Glaucoma

	You	Family	No
Computer Vision Syndrome
Macular Degeneration
Vitreous Detachment

	You	Family	No
Retinitis Pigmentosa
Blood/Lymph
Color Blindness

Medical History

Do you or your immediate family currently experience problems or conditions in any of the following categories?:

	You	Family	No
Diabetes
Gastrointestinal
Ears/Nose/Throat
Cardiovascular
Respiratory

	You	Family	No
High BP
Nervous System
Genitourinary
Musculoskeletal
Mental

	You	Family	No
Endocrine
Blood/Lymph
Allergic/Immune
Allergies
Medication

Please list any medical or drug allergies you currently have:

Please list all medications you're currently taking:

Vitamins:

None A E C Zinc Xanten Lutein Multi Vitamin Other

Over The Counter Meds:

None Aspirin Acetaminophen Ibuprofen Other

Pregnant Or Nursing:

No Yes Unsure Other

Preferred Pharmacy:

Visual Demands

Computer Use:

Hobbies:

None Art Baseball Astronomy Boating Basketball Cooking Crafts Dancing Diving Football Fishing Golf Gardening Horseback Riding Hunting Models Needlepoint Painting Photography Piano Reading Running Roller Blading Softball Sewing Skiing Soccer Swimming Tennis Video Games Woodworking Other

Social History

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	Type:	None Cigarettes Chewing Tobacco Other	How Long:
Alcohol Use:	No Yes Occasionally Socially Other	Type:	None Beer Wine Hard Liquor Other	How Long:
Illegal Drug Use:	No Yes Other	Type:		How Long:

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