Online Patient Form

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Demographics


Patient Information
Title FirstLastMISuffixNickname
Address:
City: State/ZipCode
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/GuardianDrivers License #



Primary 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:

Secondary 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:

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:

Other

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:

Visual History

CC
Associated: Do you have any other symptoms related to this?
Other eye

I currently wear glasses: Full-Time Part-Time If part-time, how often/when?
I currently wear contacts: Full-time Part-time If part-time, how often/when? Soft Rigid Gas Permeable
Contact Lens Wearers: Are you comfortable? Yes No Current Brand:
What solution do you use? What is your replacement schedule? How old is your current pair?
Please list all eyedrops you use (OTC and Rx): How often used?:

Do you have history of any of the following?

Condition Yes No
Blindness
Eye Turn (Strabismus)
Lasy Eye (Amblyopia)
Keratoconus
Glaucoma
Cataracts
Macular Degeneration
Retinal Detachment

Are you experiencing any of the following?

Condition Yes No
Headaches
Blurred Vision
Double Vision
Eyes 'Hurt' or 'Tired'
Halos around lights
Bothered by light/sun light
Frequent styes
Eyes frequently red

Are you experiencing any of the following?

Condition Yes No
Eyes itch
Eyes burn
Eyes tear
Eyes feel dry
Eyes feel sandy/gritty
Flashing lights
Floaters


Other eye disease or condition Describe any eye injuries: List any eye surgeries:


Medical History/Review Of Systems

Physician's Name: Physician's Phone: Fax: Last Visit Date:

List all medications you are currently taking (including any OTC/vitamins): No Prescription Meds
Drug Allergies: No Drug Allergies

If yes, what is the due/birth date?
Are you pregnant or nursing? Yes No If yes, what is the due/birth date?
History of seizures? Yes No

Review Of Systems


Do you have, or ever had, any CHRONIC problems in the following areas?


General
Ear, nose and throat
Cardiovascular
Respiratory
Genital, kidney and bladder
Muscles, bones and joints
Gastrointestinal
Skin
Neurological
Psychiatric
Endocrine
Blood/lymph
Allergic/immunologic


Family History/Social History


Family History Family history is unknown/adopted


Condition Yes No Relationship To Patient
Poor Vision
Blindness
Eye Turn (Strabismus)
Lazy Eye (Amblyopia)
Glaucoma
Cataracts
Macular Degeneration
Retinal Detachment/Disease
Condition Yes No Relationship To Patient
Cancer
Diabetes
High Blood Pressure
Stroke
Thyroid Disease
Other Inherited Disease
If Yes, What Disease?

Social History


Do you have? Hepatitis HIV STD's

Occupation:
Employer:

How often do you consume alcohol:
Smoking Status
Ethnicity
Preferred Language
Race

Who referred you to our office?
If not referred, how did you hear about Total Vision Eyecare?


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