Online Patient Forms

Patient information

First name

*This field is required

Last name

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Nickname

Birth Sex

Male Female

Address

Apt/Suite #

City

State

Zip Code

Cell Phone

*This field is required

Home Phone

Preferred Contact Method

Birthday

SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Pronoun

Gender Identity

Marital Status

Misc/Guardian

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Eye History

Primary Reason for Visit

Secondary Reason for Visit

Do you currently have any of these symptoms?

Do you currently take any of these medications?

Have you had any eye surgeries? Please describe

Last Appointment Type

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

Eye History Questionnaire:

1. How frequently do your eyes feel dry, gritty, or scratchy?

2. How frequently do your eyes feel sore or irritated?

3. How frequently do you feel your eyes burning or watering?

4. How frequently do your eyes feel fatigued?

5. Is your vision worse at the end of the day?

6. Do you get headaches of any severity each week, usually getting worse later in the day?

7. Do you feel stiffness/pain in your neck/shoulders when you work at a computer or read?

8. Do you feel discomfort with computer use in your eyes (redness, burning) after long hours looking at the screen?

9. Do you feel light sensitivity especially with brighter, stronger lights like fluorescents or headlights?

10. Do you feel motion sickness/dizziness/vertigo?

11. Do you grind your teeth or feel tight in your jaw?

Family Eye History

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

Unknown family eye history

Macular Degeneration

Glaucoma

Retinal Detachment

Cataracts

Lazy/Crossed Eye

Medical History

Medications No Medications

Over the Counter Medications

Vitamins

Drug allergies

Please Describe any Injuries or Surgeries you have had

Primary Care Physician

Last Visit

Reason

Pregnant or Nursing

Recent Tetanus Shot

Do you or anyone in your family have any of these medical conditions?

Diabetes

Year Dx

HbA1C

High Blood Pressure

High Cholesterol

Thyroid

Heart Conditions

Cancer

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

Patient Signatures

To view the documents Please click the blue underlined links and sign your name in the designated areas below, Thank you!

Notice of Privacy Practices -View the HIPAA Form-

Signature

Date

Patient Bill of Rights -View the Bill of Rights Form-

Signature

Date

Optomap and Dilation -View the Optomap Form-

I elect to have the Optomap procedure at an additional fee of only $39.

I elect to have dilation- please do not drive until your vision clears up in 2-3 hours

I would like to discuss further with the technician before making a decision.

I am declining the Doctors' recommendation to obtain a comprehensive view of my retinas.

AUDIOLOGY Are you interested in a complimentary hearing test with our in-clinic audiologist, Dr. Bea Smith?

Yes

Patient information

Billing information

Primary Medical Insurance

Primary Vision Insurance

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Eye History

Contact Lens Wearers only:

Eye History Questionnaire:

Family Eye History

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

Medical History

Do you or anyone in your family have any of these medical conditions?

Review of Systems

Social History

Patient Signatures