Online Patient Forms

Patient information

First name

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Last name

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Nickname

Pronoun

Address

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Apt/Suite #

City

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State

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Zip Code

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Cell Phone

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Home Phone

Work Phone

Other Phone

Preferred Contact Method

Birthday

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SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Birth Sex

Male Female

Marital Status

Misc/Guardian

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Eye History

What is the main reason for your visit today?

Do you currently have any of these symptoms?

Do you currently take any of these eye medications?

Please list any eye surgeries and/or trauma (include dates)

Last Eye Exam

By Doctor

Ophthalmologist

Last Visit

Primary Vision Correction

What type of glasses do you wear?

How old are your glasses?

Family Eye History

Does anyone in your family have any of these eye conditions?

Unknown family eye history

Macular Degeneration

Glaucoma

Retinal Detachment

Blindness

Cataracts

Lazy/Crossed Eye

Medical History:

COVID-19 Screening

Do you have any of the following: fever or chills, cough, shortness of breath or difficulty breathing, sore throat, body aches, or new loss of taste or smell?

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Have you been in close contact (within 6 feet) with someone who has a laboratory confirmed COVID-19 diagnosis in the past 14 days?

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Medications No Medications

Drug Allergies No known drug allergies

Vitamins

Over the Counter Medications

Please describe any injuries or surgeries you have had:

Primary Care Physician

Last Visit

Reason

Pregnant or Nursing

Do you have any of these medical conditions?

Diabetes

Year Diabetes Diagnosed

HbA1c

High Blood Pressure

High Cholesterol

Thyroid Conditions

Heart Conditions

Cancer

Other

Family Medical History

Unknown family history

Does anyone in your family have any of these medical conditions?

High Blood Pressure

Diabetes

Thyroid

Cancer

High Cholesterol

Heart Conditions

Other

Review Of Systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Social History

Smoking Status

Type

How long

Race

Ethnicity