Online Patient Form

Demographics

Patient Information

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

Exam Type

Comprehensive Eye Exam Comprehensive Eye Exam and Contact Lens Evaluation Medical Visit - not vision related Contact Lens follow up LASIK post op Ortho K Evaluation Ortho K follow up Dilation to complete comprehensive examination Medical follow up Special Testing only Rx Check Other

Past Ocular Complaints	None Allergic Conjunctivitis Amblyopia Cataract Diabetic Retinopathy Dry Eyes Eye infections Eye Injury Glaucoma Low vision Macular Degeneration Hx of Myopia Control Hx of Ortho K Retinal disease Strabismus Vision Therapy Other
Ocular Surgery	None Cataract Surgery Glaucoma Surgery LASIK PRK RK Retina Surgery Strabismus Surgery Other
Last Exam Date	1 year 2 years 3 years Other	Primary Vision Correction	Unknown None Glasses-Full Time Glasses-Readers Only Contacts - Soft Contacts - Hard or Specialty OTC readers Ortho K Other

Medications, Allergies, Other History

Prescription Medication - No current medications	Allergies - No known drug allergies
OTC Medication

Social History

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	Discussed Cessation	Yes No Other
Alcohol	No Yes Fomer Other	Recreational Drug use	No Yes Former Other
Occupation	Unknown Other	Digital screen use	No answer Moderate: 4 to 6 hours/day Minimal: < 3 hrs/day High: > 6 hours/day Other

Patient Medical History

Cancer	None Yes Other	Cardiovascular	None Yes Other
Hypertension	None Yes Other	High Cholesterol	None Yes Other
Thyroid	None Yes Other	Pregnant Or Nursing	No Yes Unsure Other
Other	No Yes Other
Diabetes	None Yes - T2 diabetes Yes - T1 diabetes Other	YrDx	1 yr 2 yrs 3-5 yrs 5-10 yrs 10+ yrs Other
HBA1C		Taken	> 6 Months < 6 Months 1 month ago 2 months ago 3 months ago 4 months ago 5 months ago Other
Primary Care Physician
Last Physical
Endocrinologist/specialist

Review Of Systems

General	none fatigue fever loss of appetite weight gain weight loss Other	Ear, nose and throat	none chronic cough congestion daytime drowsiness dry throat / mouth gasp while sleeping headache hearing problems heavy snoring morning headaches runny nose sinus problems sleep apnea tinnitus toothache Other
Cardiovascular	none chest pain heart disease high blood pressure high cholesterol low blood pressure racing heartbeat shortness of breath swollen feet/ankles vascular disease Other	Respiratory	none asthma cronchitis cyanosis emphysema productive cough shortness of breath sinus problems wheezing Other
Genital, kidney and bladder	none impotence jaundice overactive bladder painful urination painful urination underactive bladder urgency in urination urinary incontinence Other	Muscles, bones and joints	none arthritis decreased range of motion multiple sclerosis muscle cramps pain/tenderness rheumatoid arthritis stiffness swelling weakness Other
Gastrointestinal	none abdominal pain acid reflux bloody stools constipation Crohn's disease dark urine diarrhea gastric reflux (GERD) IBS jaundice nausea ulcer vomiting Other	Skin	none acne eczema itching psoriasis rosacea Other
Neurological	none balance problems changes in senses dementia epilepsy/seizures memory problems migraines muscle weakness numbness, paralysis personality changes speech problems tremors vertigo Alzheimer's Diseasae Parkinson's Disease Other	Psychiatric	none anxiety depression insomnia obsessive/compulsive paranoia suicidal violence Other
Endocrine	none T1 diabetes T2 diabetes hypothyroid hyperthoyroid Other	Blood/lymph	none anemia bleeding gums cuts slow to clot easy bruising hx of significant blood loss nosebleeds pale skin pounding in ears rapid heartbeat shortness of breath Other
Allergic/immunologic	none asthma hives itching mild allergy symptoms redness severe allergy symptoms sneezing swelling Other	Injuries/Surgeries	None Other

Family Medical History

Cancer	None M F Sibling GM GF Other Unknown Other	Diabetes	None M F Sibling GM GF Other Unknown Other
Cardiovascular	None M F Sibling GM GF Other Unknown Other	Hypertension	None M F Sibling GM GF Other Unknown Other
High Cholesterol	None M F Sibling GM GF Other Unknown Other	Thyroid	None M F Sibling GF GM Unknown Other
Amblyopia/Strabismus	None M F Sibling GM GF Other Unknown Other	Blindness	None M F Sibling GM GF Other Unknown Other
Cataracts	None M F Sibling GM GF Other Unknown Other	Glaucoma	None M F Sibling GM GF Other Unknown Other
Macular Degeneration	None M F Sibling GM GF Other Unknown Other	Retinal Detach	None M F Sibling GM GF Other Unknown Other
Other

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Retinal Examination, Examination and Billing Protocols, Optical Policies - Richmond location only, Patient Owned Frames - Richmond location only, Notice of Privacy Practices, Authorization and Consent

View Retinal Examination, Examination and Billing Protocols, Optical Policies, Patient Owned Frames, Notice of Privacy Practices, Authorization and Consent

Please select one of these two options:

I would like Optomap retinal imaging. I agree to the $39.00 fee for service. I understand that this new technology is not covered by my insurance. Reduced to $29.00 for returning patients.

I prefer dilation with eye drops. I understand that my near vision will be blurry, and my eyes may be light sensitive for up to 6 hours. I understand that I am not supposed to drive more than 3 miles, or operate any machinery until I feel like my vision has suitably recovered.

ELECTRONIC SIGNATURE (Guardian if under 18 years of age):
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Examination and Billing Protocols, Optical Policies, Patient Owned Frames, Notice of Privacy Practices, Authorization and Consent Signature

ELECTRONIC SIGNATURE (Guardian if under 18 years of age):
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