Online Patient Form

Demographics

Patient Information

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

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:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed	Employer / School Name
Misc/Guardian		Drivers License #

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Billing Information

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

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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:

Medical History

CHIEF COMPLAINT	SECONDARY COMPLAINT

Glasses History	Type
No Prior Prescription	Single Vision Distance Only
Glasses Lost	Single Vision Reading Only
Glasses Broken	Lined Bifocal
Scratched	Lined Trifocal
Did Not Bring Glasses	Progressive
History Progressive Non Adapt
Current Prescription Working Well

Contact Lens History

Last Worn Contact Lenses	never today days weeks months years Other
Interest in trying

Patient Ocular History

Condition	Yes	No
Heart Disease
High Blood Pressure
High Cholesterol
Asthma / Allergies
Stroke
Diabetes
Thyroid Conditions
Lupus
Cancer
HIV / Hepatitis
Multiple Sclerosis
Glaucoma
Macular Degeneration
Retinal Disease
Crossed / Lazy Eyes
Blindness
Color Blindness

Other Patient Ocular Conditions	Eye Surgeries
Eye Injuries

Medications - No known drug allergies	Allergies - No current medications
Pharmacy

Other Patient Medical Conditions	Patient Surgical History

Psychiatric:	Normal Depression Anxiety Agitation Other
Neurological:	Yes No Other
Race	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander Other Race Patient Declined to Specify White Other
Ethnicity	Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Other
Preferred Language	English Spanish French Patient Declined to Specify Abkhazian Afar Afrikaans Akan Albanian Amharic Arabic Aragonese Armenian Assamese Avaric Avestan Aymara Azerbaijani Bambara Bashkir Basque Belarusian Bengali Bihari languages Bislama Bokm?l, Norwegian), Norwegian Bokm?l Bosnian Breton Bulgarian Burmese Catalan; Valencian Central Khmer Chamorro Chechen Chichewa; Chewa; Nyanja Chinese Church Slavic; Old Slavonic; Church Slavonic; Old Bulgarian; Old Church Slavonic Chuvash Cornish Corsican Cree Croatian Czech Danish Divehi; Dhivehi; Maldivian Dutch; Flemish Dzongkha Esperanto Estonian Ewe Faroese Fijian Finnish Fulah Gaelic; Scottish Gaelic Galician Ganda Georgian German Greek, Modern (1453-) Guarani Gujarati Haitian; Haitian Creole Hausa Hebrew Herero Hindi Hiri Motu Hungarian Icelandic Ido Igbo Indonesian Interlingua (International Auxiliary Language Association) Interlingue; Occidental Inuktitut Inupiaq Irish Italian Japanese Javanese Kalaallisut; Greenlandic Kannada Kanuri Kashmiri Kazakh Kikuyu; Gikuyu Kinyarwanda Kirghiz; Kyrgyz Komi Kongo Korean Kuanyama; Kwanyama Kurdish Lao Latin Latvian Limburgan; Limburger; Limburgish Lingala Lithuanian Luba-Katanga Luxembourgish; Letzeburgesch Macedonian Malagasy Malay Malay Malayalam Maltese Manx Maori Maori Marathi Marshallese Mongolian Nauru Navajo; Navaho Ndebele, North; North Ndebele Ndebele, South; South Ndebele Ndonga Nepali Northern Sami Norwegian Norwegian Nynorsk; Nynorsk, Norwegian Occitan (post 1500) Ojibwa Oriya Oromo Ossetian; Ossetic Pali Panjabi; Punjabi Persian Polish Portuguese Pushto; Pashto Quechua Romanian; Moldavian), Moldovan Romansh Rundi Russian Samoan Sango Sanskrit Sardinian Serbian Shona Sichuan Yi; Nuosu Sindhi Sinhala; Sinhalese Slovak Slovenian Somali Sotho, Southern Sundanese Swahili Swati Swedish Tagalog Tahitian Tajik Tamil Tatar Telugu Thai Tibetan Tigrinya Tonga (Tonga Islands) Tsonga Tswana Turkish Turkmen Twi Uighur; Uyghur Ukrainian Urdu Uzbek Venda Vietnamese Volap?k Walloon Welsh Western Frisian Wolof Xhosa Yiddish Yoruba Zhuang; Chuang Zulu Other

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
Alcohol Use	None Social Use Heavy use Alcoholic Recovering Alcoholic Other
Illegal Drug	None Social Use Heavy use Other

Primary Care Physician
Referring Physician
Ref Phy Phone
Other Physicians
Last Medical Dr Appt

Family History

Condition	Yes	No
Heart Disease
High Blood Pressure
High Cholesterol
Asthma / Allergies
Stroke
Diabetes
Thyroid Conditions
Lupus
Cancer
HIV / Hepatitis
Multiple Sclerosis
Glaucoma
Macular Degeneration
Retinal Disease
Crossed / Lazy Eyes
Blindness
Color Blindness

Other Family Ocular Conditions

Other Family Medical Conditions - Family History Unknown

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