Online Patient Forms

Patient Information

First Name

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Last Name

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Nickname

Birth Sex

Male Female

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Address

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Apt/Suite #

City

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State

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Zip Code

*This field is required

Cell Phone

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Home Phone

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Preferred Contact Method

Birthday

(MM/DD/YYYY)

*This field is required

SSN

Occupation

Employment Status

Employed Fulltime Student Parttime Student

Employer/School Name

Pronoun

Gender Identity

Marital Status

Misc/Guardian

Billing Information

Is The Billing Address Different?

Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

Apt/Suite:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Interested in learning more about Cherry Financing or Care Credit for services and/or materials? Yes No

Medical History

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

Eye History

What is the Main Reason for Your Visit Today?

Have you had any of these symptoms in the last year?

Do you currently use any of these eye drops?

Last Eye Exam

Glasses History:

Primary Vision Correction

How old are your glasses?

Where are your last pair of glasses from?

Contact Lens Wearers only:

What Brand Do You Wear?

When Have you Last Worn Contact Lenses

Interest In Trying?

Type of Contacts worn in the past

Do You Sleep In CLs?

How often do you throw away your contacts?

Solution

Do you have backup glasses?

Medical History

Medications No Medications

Over the Counter Medications

Vitamins

Drug allergies No Known Drug Allergies

Environmental Allergies

Please describe any eye injuries or eye surgeries you have had:

Primary Care Physician

Last Visit

Reason

Pregnant or Nursing

Review Of Systems

Constitution (Current)

Ear/Nose/Throat

Neurology

Psychology

Cardiovascular

Respiratory

Gastrointestinal GI

Genitourinary GU

Musculoskeletal

Integumentary

Lymphatic/Hem

Allergy/Immune

Endocrine

Years with Diabetes if applicable

HBA1C

Mobility

Cancer

Social History

Hobbies

Smoking Status

Alcohol Use

Marijuana Use

Illegal Drug

Race / Ethnicity

Preferred Language

If preferred language is not English, do you need a translator?

Referring Physician

Referring Physician Phone

Other Physicians

Last Medical Doctor Appointment

Family Medical History

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

Unknown family history

High Blood Pressure

Diabetes

Thyroid

Cancer

Heart Disease

Other

Family Eye History

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

Macular Degeneration

Glaucoma

Retinal Detachment

Blindness

Cataracts

Lazy/Crossed Eye

Office Policies Agreement

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