Online Patient Forms

Please fill out to the best of your ability.

Questions? Call us at (425) 788-2990

Demographics





Home Phone: Work Phone:
Other Phone:
Cell Phone: Preferred Contact Method:
Email
Birthday (xx/xx/xxxx) Occupation
Sex Male Female
Marital Status Employer/School Name
Misc/Guardian

How did you hear about us?:

Medical History



Please list other doctors you currently see:
Please list eye medications you currently take:
Please list other medications you currently take:
Please list any supplement or over-the-counter
medications you currently take:
Please list medication allergies:
Please list any major injuries or surgeries:
Pregnant Or Nursing?

Review of Systems

Do you currently have problems in any of these areas? If yes, please explain:

GENERAL: Chronic fever or fatigue, unexpected weight gain or loss     No
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth No
CARDIOVASCULAR: High BP, Heart disease, Vascular Disease No
RESPIRATORY: Asthma, Emphysema, COPD, Sleep apnea No
GENITAL, KIDNEY, BLADDER: Kidney disease, frequent urination No
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury No
SKIN: Skin cancer, rashes, Rosacea, Psoriasis No
NEUROLOGICAL: Headaches/migraines, seizures, MS, autism, other No
PSYCHIATRIC: Depression, Anxiety, Insomnia, Panic disorder No
ENDOCRINE: Thyroid, Diabetes, Pituitary No
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems No
IMMUNOLOGIC / ALLERGY: Rheumatoid, Lupus, Allergies, HIV+ No
GASTROINTESTINAL: IBS, Crohn's, frequent cramping No
CANCER: Current or prior No

Social History

Height: ft. in.
Weight: lbs.
Smoking status:
Alcohol:
Preferred Language:
Race:
Ethnicity:

Patient Ocular History

Are you currently experiencing?   Do you have, or have you been told you have:
No Yes   No Yes
Blurred vision   Glaucoma
Dry, irritated eyes   Macular Degeneration
Floaters   Retinal Detachment
Flashes of light   Lazy / Crossed eye
Double vision   Cataract
Itching eyes   Serious eye injury
Additional eye history:
Other current symptoms:
Eye Surgery or Laser: No Yes

Family Eye History

Glaucoma: No Yes
Macular Degeneration: No Yes
Retinal Detachment: No Yes
Lazy / Crossed eye: No Yes

Family Medical History (parents and siblings only)

Diabetes: No Yes
Heart Disease: No Yes
Cancer: No Yes
Other: No Yes

Lifestyle Index

Headaches of any severity each week, usually getting worse later in the day
Stiffness / Pain In Neck / Shoulders when you work at a computer or read
Discomfort with Computer Use in your eyes (redness, burning) after long hours looking at the screen
Tired Eyes with increasing feeling of eye fatigue throughout the day
Dry Eye Sensation feeling progressively more gritty/sandy while working at computer or reading
Light Sensitivity especially with brighter, stronger lights like fluorescents or headlights
Dizziness or an experience like motion sickness or vertigo

Lifestyle Eye History

Please tell us about your hobbies and sports activities:
Do you have only one pair of current Rx glasses?
Are your prescription sunglasses older than your latest glasses prescription?
Do you have difficult driving at night or in bright sunshine?
Do your eyes get tired or your vision blurry when using a computer?
More people than ever can be fit with contact lenses,
if you don't already wear them would you like to try contacts?
Would you like information on laser vision correction?

All Ready?