Online Patient Form

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Patient Information


TitleFirstLastMISuffixNickname
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name
Misc/Guardian

Billing Information

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

Primary Medical

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary Medical

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Vision

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Vision Secondary

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Eye History

Reason for Visit: Secondary Reasons:

Do you currently have any of these symptoms?:
Do you take any of these eye medications?:
Last Eye Exam: By Doctor:

Primary Vision Correction:
Do you:    Have back up glasses? Want new glasses? Want backup sunglasses?:

Contact Lens Wearers only
Type of contacts worn in the past: Cleaner: Disposal:
Wear Time: Hours Per Day: Days Per Week Comfortably:

Medical History

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:
Endocrinologist/Specialist Other Eyecare Professional


Do you have any of these medical conditions?:

Diabetes: Year Diagnosed:
High Blood Pressure:
High Cholesterol:
Thyroid Conditions:
Heart Conditions:
Cancer:
Respiratory:
Skeletal:
Gastro:
Other:

Family Medical History



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

High Blood Pressure: Diabetes:
Thyroid Conditions: High Cholesterol:
Heart Conditions: Other:
Cancer:

Family Eye History

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

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


Dry Eye History

Frequency legend: (rate on a scale of 3: 0= Never, 1= Sometimes, 2= Often, 3= Consistant)

Severity legend: (rate on a scale of 4: 0= No problems, 1= Tolerable, 2= Uncomfortable, 3= Bothersome, 4= Intolerable)

Symptoms Frequency Of Symptoms Severity Of Symptoms Symptoms at This Visit Symptoms Within Past 72 Hours Symptoms Within Past 3 Months
Dryness,Grittiness or Scratchiness                   YESNO YESNO YESNO
Soreness or Irritation                   YESNO YESNO YESNO
Burning or Watering                     YESNO YESNO YESNO
Eye Fatigue                     YESNO YESNO YESNO
Fluctuating Vision                     YESNO YESNO YESNO




OCULAR SURFACE DISEASE INDEX

OSDI Legend:(rate on a scale of 4: 0= Never, 1= Rarely, 2= Sometimes, 3= Often, 4= Always)



Uncomfortable in the following?
Windy conditions?
Low humidty?
Air conditioning?
Limited in performing the following?
Reading?
Driving at night?
Computer use?
Watching TV?
Experienced the following?
Sensitivity to light?
Gritty feeling?
Painful or sore?
Blurred vision?
Poor vision?




Review of Systems

General: Ear/Nose/Throat:
Skin: Cardiovascular:
Respiratory: Muscles, Bones, Joints:
Psychiatric: Gastrointestinal:
Endocrine: Blood/Lymph:
Neurological: Genital, Kidney, Bladder:
Alergic: Immunologic:

Social History

Hobbies:

Smoking Status: Type: How Long:
Alcohol Use: Type: How Long:
Illegal Drug Use: Type: How Long
STD

Race: Ethnicity: Preferred Language:

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