Online Patient Form
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Patient Information
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Text Message
Email
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Birthday
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Sex
Male
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Employment Status
Employed
Full-Time Student
Part-Time Student
Marital Status
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Annulled
Divorced
Domestic partner
Interlocutory
Legally Separated
Married
Never Married
Polygamous
Widowed
Employer/School
Misc/Guardian
Billing Information
Is The Billing Address the Same?
Yes
Title:
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Mr.
Mrs.
Ms.
Dr.
Rev.
First:
Last:
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Address:
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City:
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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
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NC
ND
OH
OK
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PA
RI
SC
SD
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UT
VT
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Medical History
Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!
What is the reason for today's visit?
Date of Last Eye Exam
Primary Care Provider
Family Medical History
Unknown family history
Diabetes
Patient
Mother
Father
Sibling
No
Describe:
Hypertension
Patient
Mother
Father
Sibling
No
Describe:
Thyroid
Patient
Mother
Father
Sibling
No
Describe:
Cardiovascular Disease
Patient
Mother
Father
Sibling
No
Describe:
Cancer
Patient
Mother
Father
Sibling
No
Describe:
Pregnant/Nursing
No
Unsure
Pregnant
Nursing
Other
Last Physical Exam
Review Of Systems
Major Injury/Surgery
None
--Abdominal--
appendectomy
cholecystectomy
gastric by-pass
hernia repair
lap band
--ENT--
adenoidectomy
sinus surgery
tonsillectomy
tympanostomy
--Ortho--
broken ankle
broken leg
broken wrist
carpal tunnel
herniated discs
hip replacement
knee sx
knee replacement
shoulder sx
--ObGyn--
C-section
DandC
hysterectomy
lumpectomy
mastectomy
ovariectomy
tubal ligation
--Neuro--
brain aneurism
brain hem
brain tumor
concussion
spinal cord injury
TBI
--Thoracic--
abdominal aneurism
aortic aneurism
coronary bypass
coronary stent
hiatal hernia
heart valve repair
heart valve replacement
pacemaker
pacemaker/defribrillator
--Urology--
prostatectomy
vasectomy
Other
Constitutional
good
fever
fatigue
loss of appetite
weight gain
weight loss
Other
Ear, Nose, Throat
None
chronic cough
congestion
daytime drowsiness
dry mouth/throat
gasp while sleeping
headache
hearing problems
heavy snoring
morning headaches
runny nose
sinus problems
sleep apnea
tinnitus
toothache
hypercholesterolemia
Other
Cardiovascular Disease
None
chest pain
hypertension
cholesterol
racing heartbeat
shortness of breath
swollen feet/ankles
TIAs
Other
Pulmonary
None
asthma
chronic cough
cyanosis
productive cough
shortness of breath
wheezing
Other
Genitourinary
None
overactive bladder
painful urination
underactive bladder
urgency in urination
urinary incontinence
Other
Gastrointestinal
None
abdominal pain
bloody stools
constipation
dark urine
diarrhea
gastric reflux (GERD)
jaundice
nausea
vomiting
Other
Endocrine
None
addison's disease
adrenal gland disorder
connective tissue disease
cushing's disease
gigantism
graves disease
growth hormone disease
hashimoto thyroiditis
lupus
marfan syndrome
myocarditis
pituitary disease
polycystic ovary syndrome
polyendocrine syndrome
polymyositis
rheumatoid arthritis
sjogren syndrome
---Hyperthyroid---
heat intolerance
sweaty
diarrhea
mood swings
palpitations
weight loss
decreased menstruation
---Hypothyroid---
cold intolerant
fatigue
depression
hair loss
heavy periods
constipation
dry skin
---Diabetes---
frequent urination
thirst
hunger
dizziness
sweating
headache
---Adrenal---
chronic hypotension
darkening of skin
---Reproductive---
menstrual changes
changes in libido
ED
Other
Musculoskeletal
None
arthritis
decreased range of motion
gout
joint pain
muscle cramps
pain/tenderness
rheumatoid arthritis
stiffness
swelling
weakness
Other
Skin
None
acne
blisters
cysts
dandruff
eczema
erythema
growths
nodules
psoriasis
rash
rosacea
scales
seborrheic / actinic keratosis
ulcerations
warts
Other
Neurological
None
alzheimer
balance problems
changes in senses
dementia
memory problems
muscle weakness
numbness/tingling
personality changes
schizophrenia
speech problems
tremors
vertigo
Other
Psychiatric
None
anxiety
changes in eating habits
changes in sex drive
delusions
depression
excess anger
excessive worrying
frequent mood changes
hallucinations
insomnia
obsessive/compulsive
paranoia
social withdrawal
substance abuse
suicidal
violence
Other
Hematologic / Lymphatic
None
aids
anemia
arthritis
auto-immune disease
hodgkin lymphoma
lupus
lymphoma
rhematoid arthritis
bleeding gums
cuts slow to clot
easy bruising
heavy periods
hx of significant blood loss
jaundice
nosebleeds
pale skin
pounding in ears
rapid hearbeat
shortness of breath
Other
Allergic / Immune
None
asthma
hiv
hives
itching
mild allergy symptoms
severe allergy symptoms
redness
sneezing
swelling
Other
Other Medical History
None
acid reflux
acne rosacea
Alzheimer's dz
ankylosing spondylitis
anxiety
asthma
atherosclerosis
atrial fib
autism
benign prostatic hyperplasia
bipolar
carpal tunnel syndrome
Celiac dz
chronic fatigue
cluster headaces
congestive heart failure
COPD
Crohn's dz
dementia
depression
diverticulitis
Down syndrome
eczema
emphysema
endometriosis
epilepsy
erectile dysfunction
fibromayalgia
gallstones
GERD
gonorrhea
gout
heart attack
hepatitis
herpes simplex
HIV/AIDS
hypercholesterolemia
hyperlipidemia
hypertriglyceridemia
IBS
insomnia
kidney dz
kidney stones
migraine
multiple sclerosis
myasthenia gravis
osteoarthritis
Parkinson'd dz
polycystic ovary syndrome
psoriasis
rheumatoid arthritis
sarcoidosis
schizophrenia
shingles
sinusitis
sleep apnea
systemic lupus (SLE)
TB
temporal arteritis
vertigo
Other
Eye Conditions
Glaucoma
Patient
Mother
Father
Sibling
No
Describe:
Macular Degeneration
Patient
Mother
Father
Sibling
No
Describe:
Retinal Detachment / Tear
Patient
Mother
Father
Sibling
No
Describe:
Cataract
Patient
Mother
Father
Sibling
No
Describe:
Lazy eye / Eye turn
Patient
Mother
Father
Sibling
No
Describe:
Ocular Injury/Surgery/Laser
None
Anti-VEGF tx
blepharoplasty
corneal transplant
cryo
ECCE/IOL
filtering procedure
focal laser
grid laser
laser trabeculoplasty
LASIK
LPI
peripheral retinal laser
PRK
PRK
PRP
ptosis repair
RD repair
RK
scleral buckle
SLT
strab sx
stromal puncture
valve
YAG cap
Other
Other Ocular History
None
choroidal nevus
episcleritis
chalazia
frequent styes
corneal ulcers
GPC
keratoconus
Fuch's endothelial dystrophy
uveitis
Other
Eye Medications / Over-the-counter drops
None
Art Tears
Oasis Tears
Refresh
Systane
Blink
Visine
Restasis
Xiidra
Other
Marital Status
Annulled
Divorced
Domestic Partner
Interlocutory
Legally Separated
Married
Never Married
Polygamous
Widowed
Other
Referred By
Other
Occupation/Grade
student
Other
Employer/School
Parent/Guardian
LiveAlone
assisted living
No
nursing home
Yes
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
None
social
occasional
1-2 drinks/day
several drinks/day
Other
Other Medications
None
Accupril / Quinapril
Aciphex / rabeprazole
Actonel / risedronate
Actos
Acyclovir
Adderall
Advair Diskus
Albuterol
Allegra / fexofenadine
alprazolam
Altace / ramipril
Amaryl / glimepiride
Ambien / zolpidem
Amiodarone
amlodipine
amoxicillin
Aricept / donepezil
Arimidex / Anastrozole
Atacand / candesartan
atenolol
Augmentin
Avandia / rosiglitazone
Avapro / irbesartan
azithromycin
BCP
Buspar
Captopril
Carbamazepine
Casodex / bicalutamide
Celebrex
Celexa / celecoxib
Cialis
Cipro / ciprofloxacin
citalopram
Clarinex / desloratadine
Clonidin
Combivent / albuterol-ipratropium
Coreg / carvedilol
Coumadin / warfarin
Cozaar / losartan
Crestor
Depakote
Detrol / tolterodine
Diclofenac
Dilantin
Diovan / valsartan
Ditropan XL / oxybutynin
Effexor / venlafaxine
Evista / raloxifene
Exelon / rivastigmine
Flomax / tamsulosin
Flonase / fluticasone
Flovent / fluticasone
Fosamax / alendronate
furosemide
gabapentin
Glucophage / metformin
Glucotrol / Glipizide
Glyburide
HCTZ
Humulin / insulin
hydrocodone-acetaminophen
Hydrocortisone
Hyzaar losartan
Lanoxin / digoxin
Lantus / insulin
Lasix
Lescol / fluvastatin
Levaquin / levofloxacin
levothyroxine
Levoxyl
Lexapro / escitalopram
Lipitor / atorvastatin
lisinopril
Lotensin / benazepril
Lotril / amlodipine-benazepril
metformin
Methlyprednisolone
metoprolol
Mobic / meloxicam
Monpril / fosinopril
Nasacort
Nasonex / mometasone
Neurontin / gabapentin
Nexium / esomeprazole
Norvasc / amlodipine
Novalog
omeprazole
Oxycodone
Oxycontin / oxycodone
Paxil / paroxetine
Pepcid
Plaquenil
Plavix / clopidogrel
Pletal / cilostazol
Pravachol / pravastatin
Prednisone
Premarin / estrogen
Prempro
Prevacid / lansoprazole
Prilosec / omeprazole
Procar / finasteride
Protonix / pantoprazole
Proventil
Prozac
Risperdal / risperidone
Ritalin
Seroquel / quetiapine
sertraline
simvastatin
Singulair / montelukast
Synthroid / levothyroxine
Tetracycline
Topamax
Toprol / metoprolol
Tricor / fenofibrate
Ultracet / tramadol-acetominophen
Valium
Viagra / sildenafil
warfarin
Wellbutrin / bupropion
Xanax
Zantac
Zestril
Zetia / ezetimibe
Zithromax / azithromycin
Zocor / simvastatin
Zoloft / sertraline
zolpidem
Zyrtec
Other
No current medications
Allergies
Other
No known drug allergies
Vitamins / Supplements
None
Multi-vitamins
Vit A
Vit B Complex
Vit B12
Vit C
Vit D
Vit E
biotin
Calcium
Fe
Mg
Mn
Zn
Biotears
Fish Oil
Flax
Evening Primrose oil
Borage oil
Glucosamine
Chondroitin
MSM
niacin
CoQ10
zeaxanthin
Lutein
iCaps Lutein & Omega 3
Macula Complete
Ocuvite / I-caps
Preservision AREDS 2
Preservision
Ginko-Biloba
resveratrol
St John's wort
Red Yeast Rice
Juice+
curcumin
garlic
green tea extract
probiotic
Stinging nettle
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
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