Online Patient Forms

Patient information

First name

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Last name

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Nickname

Birth Sex

Male Female

Address

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SSN

Occupation

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Billing information

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Title

First

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Primary Vision Insurance

Insurance Information

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Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Birth Sex:

Male Female

Address:

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Birthday:

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Secondary Vision Insurance

Insurance Information

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Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Birth Sex:

Male Female

Address:

City:

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Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Primary Medical Insurance

Insurance Information

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account: Not Primary

Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Secondary Medical Insurance

Insurance Information

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account: Not Primary

Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

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Medical History

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

Last Exam Date

Primary Vision Correction

Do you:

Have Backup Glasses?

Want New Glasses?

Have Backup Sunglasses?

Contact Lens Wearers only:

Type of Contacts worn in the past

Cleaner

Disposal

Wear Time

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

Reason

Pregnant or Nursing

Recent Tetanus Shot

Recent Flu Immunization

Do you have any of these medical conditions?

Diabetes

Year Diabetes diagnosed if applicable

Hypertension

High Cholesterol

Thyroid Conditions

Heart Conditions

Cancer

Other

Family Medical History

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

Unknown family history

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?

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

OSDI (Ocular Surface Disease Index) Speed Test

Frequency Legend: (rate on a scale of 3: 0 = Never, 1 = Tolerable, 2 = Often, 3 = Consistant)
Severity Legend: (rate on a scale of 4: 0 = No Problems, 1 = Tolerable, 2 = Uncomfortable, 3 = Bothersome, 4 = Intolerable)

Symptoms	Symptoms at This Visit	Symptoms Within Past 72 Hours	Symptoms Within Past 3 Months
Dryness, Grittiness, Scratchiness	Yes No	Yes No	Yes No
Soreness or Irritation	Yes No	Yes No	Yes No
Burning or Watering	Yes No	Yes No	Yes No
Eye Fatigue	Yes No	Yes No	Yes No
Fluctuating Vision	Yes No	Yes No	Yes No

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

Experienced In The Following?	Limited In Performing The Following?	Uncomfortable In The Following?
Sensitivity To Light?	Reading?	Windy Conditions?
Gritty Feeling?	Driving At Night?	Low Humidity?
Painful Or Sore?	Computer Use?	Air Conditioning?
Blurred Vision?	Watching TV?	Poor Vision?

Enhance Your Eye Health with Advanced Screening

At Andrew Stone Optometry, we are committed to providing the highest level of care to help you preserve your vision and maintain your overall eye health. To support this, we recommend the following advanced imaging tests in addition to your comprehensive eye exam. These tests provide a deeper understanding of your eye health and allow us to detect potential issues before they become serious. Even if your eyes are healthy now, these screenings create a critical baseline that helps us monitor any changes in your vision over time.

Our goal is to offer these tests to all new patients and encourage established patients to build this baseline for long-term monitoring and preventative care.

OptoMap Retinal Imaging - $39

The OptoMap is a quick, painless test that takes a wide-angle image of the back of your eye (the retina) without dialation. This test provides a clear overview of your retinal health and is our basic standard of care for detecting early signs of conditions like glaucoma, macular degeneration, and diabetic retinopathy.

Why it's important: The OptoMap is the minimum recommendation for all patients, as it offers a broad view of the retina, allowing us to catch any visible retinal issues. It also helps create a baseline for future comparisons. While the OptoMap provides essential information, more detailed tests are recommended for a comprehensive view of your eye health.

OCT (Optical Coherence Tomography) - $60

OCT is a more advanced imaging test that goes beyond the surface of the retina, providing cross-sectional images of the deeper retinal layers. This detailed scan allows us to detect diseases such as glaucoma, macular degeneration, and diabetic eye disease early-even before symptoms arise.

Why it's important: OCT is recommended for patients looking for a more in-depth assessment of their eye health. It complements the OptoMap by giving us a closer look at the retina's internal structure, helping us detect subtle changes that might not be visible with a surface-level image alone.

Visual Field Testing - $45

This test measures your peripheral (side) vision to detect any blind spots or vision loss, which may be caused by conditions like glaucoma or optic nerve damage.

Why it's important: Visual Field Testing provides crucial information about the function of your overall visual field, helping us identify issues with peripheral vision that could signal broader eye health concerns.

Why We Recommend All Three Tests

While the OptoMap is a valuable and minimum standard of care for understanding the surface of your retina, the OCT and Visual Field Testing provide a more detailed and comprehensive assessment. OptoMap helps us detect visible issues, but the Complete Advanced Screening Package, which includes all three tests, is the recommended option to give us the most thorough understanding of your eye health. Together, these tests allow us to establish a baseline and monitor for any changes over time, ensuring that we catch potential problems early.

Complete Advanced Imaging Package (All 3 Tests) - $115

By choosing the complete package, you'll receive all three advanced screenings at a discounted rate. This package provides the most thorough assessment of your eye health by combining OptoMap, OCT, and Visual Field Testing.

Advanced Imaging Package

OptoMap Only Exam