Lifetime Eye Care - Online Forms for New Patients

Lifetime Eye Care - Online Forms for New Patients

New patients at Lifetime Eye Care are asked to fill out patient forms prior to their appointment. Please fill out all information below as completely as possible. Be sure to click the "Submit" button at the bottom when finished to securely submit the forms.

Returning Patient? If you are a returning patient, follow this link for returning patients
Having trouble? Call or email our office, or download PDF forms to print


Lifetime Eye Care
Murray S. Pratt, O.D.
3961 E. Chandler Blvd, Suite 106,
Phoenix, AZ 85048
(480) 706-3060
azlifetime@gmail.com
www.azlifetime.com

Demographics

TitleFirstLastMISuffixNickname
Address:
City:
State:    Zip Code:
Home Phone:
Work Phone:
Other Phone:
Cell Phone:
Email:
Preferred Contact Method:
SSN
Birthday
Sex Male Female
Marital Status
Occupation
Employer/School Name
Billing Information Check box if billing information is same as above
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:
Why did you choose Lifetime Eye Care?
When was your Last Eye Exam?


Current Health

Current Ocular Symptoms
Please mark if you have been experiencing any of these symptoms recently:
Blurred Vision
Dry Eyes
Itchy Eyes
Watery Eyes
Crossed/Lazy Eye
Double Vision
Flashes
Floaters
Other:
No recent ocular symptoms

Current Health Issues
Please describe all your current health issues:
Current health issues:

I am currently pregnant
I am currently nursing
No current health issues
Please check if you have any of these health conditions that can specifically affect the eyes:
Diabetes
Hypertension
Cancer
Sarcoidosis
Rheumatoid Arthritis
Multiple Sclerosis
Thyroid Problems
Sjogrens Syndrome
Lupus
High Cholesterol
None of these issues
Please answer the following:
Do you use tobacco, alcohol or illicit drugs?
No, I do not
Yes (Please describe below)


Do you have any sexually transmitted diseases?
No, I do not
Yes (Please describe below)


Who is your current primary care doctor?

Medications
Please list all medications, vitamins and supplements that you currently use:
Current medications:

No current medications

Allergies
Please list all allergies to medications and environment:
Allergies:

No known drug allergies


Health History

Past Ocular History
Please describe if you have ever had any of the following:
Eye Diseases:

Eye Injuries:

Eye Surgeries:

Other Ocular Issues:

No history of ocular health issues

Past Health History
Please list all past major health issues:
Past major health issues:

No past major health issues
Please check if you have ever had problems with any of these systems:
(If you check a box, please be sure you have described those issues above in either the "current health issues" or "past major health issues" boxes)
Allergy
Cardiovascular
Constitutional
Cranial/Facial
Endocrine
Gastrointestinal
Genitourinary
Hematologic/Lymphatic
Immunological
Integumentary/Skin
Neurologic
Psychiatric
Respiratory
No history of issues with any of these systems

Family Ocular History
Please mark if your family has had any history of eye diseases or problems:
(And notate who in the family had the issue)
Cataracts  
Glaucoma  
Macular Degeneration  
Retinitis Pigmentosa  
Strabismus  
Other:
  
No family ocular conditions
Unknown family history

Family Health History
Please mark if your family has had any history of  major health problems:
(And notate who in the family had the issue)
Diabetes  
Hypertension  
Heart Disease  
Thyroid Disease  
Cancer  
Other:

No family health conditions
Unknown family history


Submit

Important: Click the button below for your information to be securely sent to us. Please complete all sections before submitting.


When you arrive for your appointment, please let a Lifetime Eye Care staff member know you submitted the online forms. Thank you!