Online Patient Forms
Patient information
First name
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Last name
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Nickname
Birth Sex
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Address
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Apt/Suite #
City
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VA
WA
WV
WI
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Zip Code
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Cell Phone
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Home Phone
Email
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Birthday
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Pronoun
he/him/his
she/her/hers
they/them/theirs
How Did You Hear About Us?
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Eye History
What is the main reason for your visit today?
Do you currently have any of these symptoms?
None
Eye strain or tired eyes
Poor night vision/glare
Dry eyes
Floaters
Frequent headaches
Light sensitivity
Red eyes
Itchy eyes
Watery eyes
Burning or stinging eyes
Eye pain or tenderness
Double vision
Flashes of light or blackouts
Other
Do you currently take any of these eye medications?
None
Refresh
Systane
Visine
Pataday
Blink
Lumify
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Please list any eye surgeries and/or trauma (include dates)
Last Eye Exam
1 year
2 years
3 years
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Last Appointment Type:
Primary Vision Correction
None
Glasses
Soft contact lenses
Hard contact lenses
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Have Back Up Glasses?
None
Yes
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Want New Glasses?
None
Yes
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Want Back Up Sunglasses?
None
Yes
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Contact Lens Wearers Only
Type Of Contacts Worn In The Past?
Family Eye History
Does anyone in your family have any of these eye conditions?
Unknown family eye history
Macular Degeneration
No
Parents
Siblings
Grandparent
Other
Glaucoma
No
Parents
Sibling
Grandparent
Other
Retinal Detachment
No
Parents
Siblings
Grandparent
Other
Blindness
No
Parents
Siblings
Grandparent
Other
Cataracts
No
Parents
Siblings
Grandparent
Other
Lazy/Crossed Eye
No
Parents
Siblings
Grandparent
Other
Medical History:
Medications
No Medications
Drug Allergies
No known drug allergies
Vitamins
Over the Counter Medications
Please describe any injuries or surgeries you have had:
Primary Care Physician
Last Visit
1 week
1 month
3 months
6 months
1 year
2 years
greater than 3 years
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Reason
Check up
Annual
Specific
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Pregnant or Nursing
Yes, pregnant
Yes, nursing
No
N/A
Unsure
Do you have any of these medical conditions?
Diabetes
Yes
No
Unsure
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Year Diabetes Diagnosed
HbA1c
High Blood Pressure
Yes
No
Unsure
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High Cholesterol
Yes
No
Unsure
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Thyroid Conditions
Yes
No
Unsure
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Heart Conditions
Yes
No
Unsure
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Cancer
Yes
No
Unsure
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Other
Family Medical History
Unknown family history
Does anyone in your family have any of these medical conditions?
High Blood Pressure
No
Parents
Siblings
Grandparent
Other
Diabetes
No
Parents
Siblings
Grandparent
Other
Thyroid
No
Parents
Siblings
Grandparent
Other
Cancer
No
Parents
Siblings
Grandparent
Other
High Cholesterol
No
Parents
Siblings
Grandparent
Other
Heart Conditions
No
Parents
Siblings
Grandparent
Other
Other
Review Of Systems
General
None
Fatigue
Fever
Loss of Appetite
Weight Gain
Weight Loss
Developmental Disorders
Other
Skin
None
Acne
Lupus
Dermatitis
Eczema
Psoriasis
Rosacea
Skin Cancer
Itching
Other
Ear/Nose/Throat
None
Neck Problems
Sinus Problems
Sore Throat (Recent)
Headache
Morning Headaches
Migraine Headache
Cluster Headache
Hearing Loss
Tinnitus
Congestion
Dry throat / mouth
Sleep Apnea
Other
Respiratory
None
Asthma
Cancer: lung
Sleep Apnea
Sarcoidosis
COPD
Emphysema
Pneumonia
Bronchitis
Shortness of breath
Wheezing
Other
Musculoskeletal
None
Arthritis
Osteoporosis
Fibromyalgia
Osteoarthritis
Muscular Dystrophy
Lupus
Decreased range of motion
Muscle cramps
Pain/tenderness
Stiffness
Swelling
Weakness
Other
Psychiatric
None
Attention Deficit Disorder
Anxiety
Brain Damage (trauma)
Panic Attacks
Alzheimer's Disease
Bi-polar
Depression
Insomnia
Obsessive/Compulsive
Paranoia
Suicidal
Violence
Other
Endocrine
None
Crohn's disease
Diabetes Type 1
Diabetes Type 2
Diabetes Suspect
Hypothyroid
Hyperthyroid
Gout
Hormone Replacement Therapy
Other
Blood/Lymph
None
Anemia
Hx of Significant Blood Loss
Hematologic Disorder
Sickle Cell Disorder
Breast Carcinoma
Lymph Node Disease
Temporal Arthritis
Cuts slow to clot
Easy bruising
Other
Neurological
None
Multiple Sclerosis
Seizure Disorder
Parkinson's Disease
Brain Tumor
Bells Palsy
Dyslexia
Headache
Balance problems
Vertigo
Tremors
Changes in senses
Dementia
Memory problems
Muscle weakness
Numbness, paralysis
Personality changes
Speech problems
Other
Immune
None
Seasonal allergies
Environmental allergies
Food allergies
Drug allergies (please specify)
Sjogren's syndrome
AIDS
Herpes Simplex
HIV Simplex
Mononucleosis
Tuberculosis
Cytomegalovirus Infection
Herpes Zoster
Lyme Disease
Sarcoidosis
Syphilis
Hives
Itching
Mild allergy symptoms
Severe allergy symptoms
Swelling
Other
Genitourinary
None
Amenorrhea
Menopause
Impotence
Jaundice
Uterine Cancer
Prostate Cancer
Kidney Stones
Pregnant
Nursing
Syphilis
Prostate Problems
Bladder Infections
STD- herpetic
STD- chlamydia
Other
Gastrointestinal
None
Acid Reflux
Crohn's disease
Gastric reflux (GERD)
IBS
Ulcer
Gall bladder problems
Jaundice
Hepatitis
Sarcoidosis
Cancer: colon
Cancer: Liver
Other
Cardiovascular
None
Congestive Heart Disease
Cardiovascular Disease
High Cholesterol
Hypertension
Arrhythmia
Heart Murmur
Heart Palpitation
Chest Pain
Arteriosclerosis
Coagulation Disorder
Mitral Valve Prolapse
Low Blood Pressure
Other
Social History
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
Smoking Status
Never smoker(Less than 100 cigs equiv)
Former smoker (nolonger smokes)
Current some daysmoker (not daily)
Light smoker(Greater than 10cigs/day)
Heavy smoker (Morethan 10 cigs/day)
Smoker (current statusunknown)
Current every day smoker
Unknown if ever smoked
Other
Type
None
Cigarettes
Chewing Tobacco
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How long
Alcohol Use
No
Yes
Occasionally
Socially
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Type
None
Beer
Wine
Hard Liquor
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How long
Illegal Drug Use
No
Yes
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Type
How long
Race
Caucasian
Black or African American
Asian
Patient Declined to Specify
American Indian orAlaska Native
NativeHawaiian or Other Pacific Islander
Other Race
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Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Unknown
Patient Declined to Specify
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Preferred Language
English
French
German
Spanish
Other
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STDs
None
Gonorrhea
Syphilis
Hepatitis
HIV
TB
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MiamiOpticalEyeCare.com
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