Online Patient Forms
Patient information
First name
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MI
Last name
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Nickname
Address
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City
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State
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VI
VA
WA
WV
WI
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Zip Code
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Cell Phone
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Home Phone
Email
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Preferred Contact Method
Home Phone
Work Phone
Cell Phone
Other Phone
Email
Date of Birth
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Last 4 of SSN
Employer/School Name
Gender
Male
Female
Misc/Guardian
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Eye History
What is the main reason for your visit today?
Date of last eye exam?
Date of last medical exam?
Last eye exam were you dialated?
Yes
No
Do you have seasonal allergies?
Yes
No
Are you taking medications?
Yes
No
Are you pregnant?
Yes
No
Do you see flashes of light in your eyes?
Yes
No
Do you see floating objects in your eyes?
Yes
No
Do you have temporary blackouts of your vision?
Yes
No
Do you have frequent headaches?
Yes
No
Do you smoke?
Yes
No
Do you drink alcohol?
Yes
No
Do you have any allergies to medications?
Yes
No
Do you wear glasses?
Yes
No
If yes, do you wear them for:
Distance
Near
Both
Do you wear contact lenses?
Yes
No
What type of contacts?
Have you ever worn contacts?
List Medication Allergies:
List medications:
List EYE medications:
Do you have:
None
High Blood Pressure
Diabetes
Lung Disease
Cancer
Heart Disease
Cholesterol
Rheumatoid Arthritis
Sarcoidosis
Seizures
Multiple Sclerosis
HIV
Thyroid
Do you or have you ever had:
None
Strabismus
Amblyopia
Keratoconus
Glaucoma
Diabetic Retinopathy
Macular Degeneration
Dry Eyes
Iritis/ Uveitis
Retinal Detachment
Retinal Disease
Optic Nerve Disease
Have you ever had eye surgery for:
NONE
Cataract
Retinal Detachment
Muscle Surgery
Trauma
Lasik/PRK
Foreign Body Removal
Other
Has anyone in your family ever had:
NONE
Blindness
Glaucoma
Diabetes
Cataracts
Macular Degeneration
Keratoconous
Occupation
Hours spent on computer
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