Online Patient Forms

Patient information

First name

*This field is required

Last name

*This field is required

Nickname

Birth Sex

Male Female

Address

Apt/Suite #

City

State

Zip Code

Cell Phone

Other Phone

Preferred Contact Method

Birthday

*This field is required

SSN

Occupation

Misc/Guardian

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Billing information

Is The Billing Address Different? Yes

Title

First

Last

Middle

Suffix

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

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MEDICAL PERSONAL and FAMILY HISTORY

Patient Review of Systems: Do you currently or have you ever had any problems in the following areas?

CONSTITUTIONAL: Fever, Weight Loss/Gain

INTEGUMENTARY (Skin):

NEUROLOGICAL: Migraines, Seizures

ENDOCRINE: Thyroid/Other Glands

EARS, NOSE, MOUTH, THROAT: Allergies, Chronic Cough

RESPIRATORY: Asthma, Chronic Bronchitis, Emphysema

VASCULAR/CARDIOVASCULAR:Diabetes,High Blood Pressure

GASTROINTESTINAL: Diarrhea, Constipation

GENITOURINARY: Kidney/Bladder

BONES/JOINTS/MUSCLES: Rheumatoid Arthritis, Joint Pain

LYMPHATIC / HEMATOLOGIC: Anemia

ALLERGIC / IMMUNOLOGIC:

PSYCHIATRIC:

If you answered YES to any of the above or have a condition not listed, please explain:

Eye Symptoms:

Last Eye Doctor:

Primary Care Physician:

Pharmacy:

Any allergies to medications:

*This field is required

Medications

List all major injuries, surgeries, and/or hospitalizations:

Height:

Feet

Inches

Weight:

Lbs

Are you currently pregnant and/or nursing?

Yes

Race

Ethnicity

Preferred Language

Please note any family history (self, parents, siblings, children; living or deceased) for the following:

Disease/Condition
Blindness	No	Yes
Cataract	No	Yes
Crossed Eye	No	Yes
Glaucoma	No	Yes
Macular Degeneration	No	Yes
Retinal Detachment/Disease	No	Yes
Arthritis	No	Yes
Cancer	No	Yes
Diabetes	No	Yes
Heart Disease	No	Yes
High Blood Pressure	No	Yes
Kidney Disease	No	Yes
Lupus	No	Yes
Thyroid Disease	No	Yes
Other

SOCIAL HISTORY

This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.

Do you use tobacco products?

Yes

If yes, amount / how long?

Do you drink alcohol?

Yes

If yes, amount / how long?

Patient information

Billing information

Primary Insurance

Secondary Insurance

Please choose from the menu options or select the option to type in your own text. Thank you!

MEDICAL PERSONAL and FAMILY HISTORY

Patient Review of Systems: Do you currently or have you ever had any problems in the following areas?

Eye Symptoms:

Height:

Weight:

Please note any family history (self, parents, siblings, children; living or deceased) for the following:

SOCIAL HISTORY

Drooping Eye Lid	NO	YES
Loss of Vision	NO	YES
Blurred Vision	NO	YES
Distorted Vision/ Halos	NO	YES
Lazy Eye	NO	YES
Loss of Side Vision	NO	YES
Double Vision	NO	YES
Dryness	NO	YES
Mucous Discharge	NO	YES
Redness	NO	YES
Sandy or Gritty Feeling	NO	YES
Itching	NO	YES
Burning	NO	YES
Foreign Body Sensation	NO	YES
Excess Tearing / Watering	NO	YES
Glare / Light Sensitivity	NO	YES
Eye Pain or Soreness	NO	YES
Chronic Infection of Eye or Lid	NO	YES
Sties or Chalazion	NO	YES
Flashes / Floaters in Vision	NO	YES
Tired Eyes	NO	YES
Eye Injury	NO	YES
Other: