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:	Text Message Cell Phone Email Work Phone Home Phone Other Phone
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

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Patient Ocular History

Patient Ocular Conditions

Ocular History

Eye Medications

Family Ocular History

Glaucoma	None Mother Father Sibling Grandparent Other
Macular Degeneration	None Mother Father Sibling Grandparent Other
Retinal Detachment	None Mother Father Sibling Grandparent Other
Cataract	None Mother Father Sibling Grandparent Other
Amblyopia / Strabismus	None Mother Father Sibling Grandparent Other
Blindness	None Mother Father Sibling Grandparent Other

Other Family Ocular Conditions

Family Medical History

Diabetes	None Mother Father Sibling Grandparent Other
Hypertension	None Mother Father Sibling Grandparent Other
Thyroid	None Mother Father Sibling Grandparent Other

Heart Disease	None Mother Father Sibling Grandparent Other
Cancer	None Mother Father Sibling Grandparent Other

Other Family Medical Conditions - Family History Unknown

Patient Medical History

Endocrine:	none diabetes neck pain other glands thyroid Other
YrDx		A1c	unknown to pt Other
Allergic/Immunologic:	none allergies Drug Allergies hay fever Lupus Sjogren's Other
Musculoskeletal:	none Arthritis Fibromyalgia Gout MS muscle/joint pain Osteoarthritis rheumatoid arthritis swollen joints Other
Cardiovascular:	none chest pain circulatory or vascular disease heart disease heart problems high blood pressure high cholesterol HTN stroke vascular disease Other
Constitutional(Current):	none fatigue fever other unexplained weight change Other
Ears, Nose, Throat:	none chronic cough dry mouth hearing loss laryngitis runny nose sinus congestion sinusitis Other
Gastrointestinal:	none Acid Reflux Celiac Disease Chrohns Disease Colitis IBS Ulcer Other
Genitourinary:	none kidney disease Prostrate Disease STD Other
Integumentary (Skin):	none Eczema excessive dryness Herpes Simplex Herpes Zoster itching Psoriasis rashes Rosacea Other
Lymphatic/Hematologic:	none anemia bleeding problems blood disorders ulcer Other
Neurological:	none alzheimer cerebral palsy dizziness epilepsy headaches migraines motion sickness multiple sclerosis numbness paralysis parkinsons seizures stroke tumor weakness Other
Psychiatric:	none ADHD anxiety bipolar depression special needs Other
Respiratory:	none asthma chronic bronchitis COPD coughing emphysema shortness of breath wheezing Other
Cancer:	none Other
Other:	none Other

Other Patient Medical Conditions

Medications - No current medications

Allergies - No known drug allergies

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

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

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
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
Ethnicity	Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Other

COVID-19 SCREENING

Within The Last 14 Days Have You Experienced Any Of The Following Symptoms:

Condition	Yes	No
Fever
Cough
Shortness Of Breath Or Difficulty Breathing
Chills
Repeated Shaking With Chills
Muscle Pain
Sore Throat
New Loss Of Taste Or Smell
Have You Traveled In The Last 14 Days?
Have You Or A Member Of Your Household Had Close Contact
With Or Cared For Someone Diagnosed With COVID-19 In The Last 14 Days?
Have You Or A Member Of Your Household Had Close Contact With Or Cared
For Someone With A Presumptive Positive Case Of COVID-19 In The Last 14 Days?
Has Anyone In Your Household Been Asked Or Required To Quarantine Based On Contact
With A Person Who Has A Confirmed Or Presumptive Positive COVID-19 Test Result Or Diagnosis,
Or Have You Been Asked To Quarantine?

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