Online Patient Forms

Patient information

First name

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Last name

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Nickname

Birth Sex

Male Female

Address

Apt/Suite #

City

State

Zip Code

Cell Phone

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Home Phone

Preferred Contact Method

Birthday

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Occupation

Misc/Guardian

Billing information

Is The Billing Address Different? Yes

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Title

First

Last

Middle

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

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Medical History

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Eye History

Reason for Visit

Primary Reason

Secondary Reason

Do you currently have any of these eye symptoms?

Do you currently take any of these medications?

Have you had any eye surgeries? Please describe

Last Eye Exam

Last Appointment Type

By Doctor

Primary Vision Correction

Do you:

Have Backup Glasses?

Want New Glasses?

Contact Lens Wearers only:

Type of Contacts worn in the past

Cleaner

Disposal

Wear Time

Medical History:

Medications No Medications

Over the Counter Medications

Vitamins

Drug allergies

Primary Care Physician

Last Visit

Reason

Pregnant or Nursing

Do you have any of these medical conditions?

Diabetes

Hypertension

High Cholesterol

Thyroid Conditions

Heart Conditions

Cancer

Year Diabetes Diagnosed

Other

Family Medical History

Unknown Family History

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

Hypertension

Diabetes

Thyroid

Cancer

High Cholesterol

Heart Conditions

Other

Family Eye History

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

Macular Degen

Glaucoma

Retinal Detach

Blindness

Cataracts

Lazy/Crossed Eye

Review Of Systems

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Social History

Hobbies

Smoking Status

Type

How long

Alcohol Use

Type

How long

Illegal Drug Use

Type

How long

Race

Ethnicity

Preferred Language

STD

Dry Eye History

Enviornmental Factors
Systemic Conditions
Systemic Meds
Ocular Meds
Artificial Tears	Times/day
Signs
Contact Lenses

Dry Eye Questionnaire

During a typical day in the past month, how often did your eyes feel discomfort?

0-Never 1-Rarely 2-Sometimes 3-Frequently 4-Constantly

When your eyes feel discomfort, how intense was this feeling at the end of the day, within two hours of going to bed?

0-Never Have it 1-Not intense at all 5-Very Intense

During a typical day in the past month, how often did your eyes feel dry?

0-Never 1-Rarely 2-Sometimes 3-Frequently 4-Constantly

When your eyes felt dry, how intense was this feeling at the end of the day, within two hours of going to bed?

0-Never Have it 1-Not intense at all 5-Very Intense

During a typical day in the past month, how often did your eyes look or feel excessively watery?

0-Never 1-Rarely 2-Sometimes 3-Frequently 4-Constantly

Total Score

0-4: Mild dry eye symptoms. 5-7: Moderate dry eye symptoms. 8+: Severe dry eye symptoms.

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