Online Patient Forms

Patient information

First name

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Last name

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Address

Apt/Suite #

City

State

Zip Code

Cell Phone

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Billing information

Is The Billing Address Different? Yes

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Title

First

Last

Middle

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

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Medical History

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Eye History

Reason for Visit

Primary Reason

Secondary Reason

Do you currently have any of these symptoms?

Do you currently take any of these medications?

Have you had any eye surgeries? Please describe

Last Appointment Type

Primary Vision Correction

Do you:

Have Backup Glasses?

Want New Glasses?

Contact Lens Wearers only:

Type of Contacts worn in the past

Cleaner

Disposal

Wear Time

Medical History:

Medications No Medications

Over the Counter Medications

Vitamins

Drug allergies

Please Describe any Injuries or Surgeries you have had

Primary Care Physician

Last Visit

Reason

Pregnant or Nursing

Recent Tetanus Shot

Recent Flu Immunization

Do you have any of these medical conditions?

Diabetes

Hypertension

High Cholesterol

Thyroid Conditions

Heart Conditions

Cancer

Year Diabetes Diagnosed

Other

Family Medical History

Unknown family history

Does anyone in your family have any of these medical conditions?

High Blood Pressure

Diabetes

Thyroid

Cancer

High Cholesterol

Heart Conditions

Other

Family Eye History

Does anyone in your family have any of these eye conditions?

Unknown family eye history

Macular Degeneration

Glaucoma

Retinal Detachment

Blindness

Cataracts

Lazy/Crossed Eye

Review Of Systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Social History

Hobbies

Smoking Status

Type

How long

Alcohol Use

Type

How long

Illegal Drug Use

Type

How long

Race

Ethnicity

Preferred Language

STD

Patient Questionnaire

Do your eyes often:

Have you ever been diagnosed with:

Do your eyelids:

Please check all that appy

I suffer from styes My eyes appear red My eyes itch, burn, or tear occasionally I am on digital devices more than 6 hours a day I wear eyeliner, mascara, or false lashes

Lifestyle Index

This questionnaire is meant to help your doctor understand what you're experiencing on a regular basis - whether it's caused by your eyes, posture, stress, etc. Your responses will help make sure you receive the best care possible.

Headaches
•You get headaches of any severity each week (even just a dull ache counts).
•Your headaches tend to get worse later in the day.

Stiffness / pain in neck / shoulders
You experience stiffness/tension in your neck/shoulders when you work at a computer or read (this might even be from your posture).

Discomfort with Computer Use
Your eyes get tired, burn, or get red easily when you work at a computer for long hours.

Tired Eyes
Your eyes feel increasingly fatigued/tired as the day goes on

Dry Eye Sensation
Your eyes progressively feel more dry/sandy/gritty while working at the computer or reading

Light Sensitivity
Bright / Strong lights (vehicle headlights, florescent lights etc.) bother you

Dizziness
You experience dizziness, motion sickness, or vertigo.