Patient Demographics & History

Have you or anyone in your home experienced any flu or cold-like symptoms in the last 14 days?*
Have you or anyone in your home been exposed to anyone with COVID?*
Name*

First NameLast Name
Preferred Name/Nickname
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Communication Preference
Primary Phone #*
Please enter a valid phone number.
Emergency Contact*
Name and Number
Release of Information (Verbal)
To whom may we speak regarding your care and/or account?
Email
example@example.com
SSN
Gender at Birth*
Date of Birth*

MonthDayYear
Race

American Indian or Alaska NativeAsianBlack or African AmericanWhite or CaucasianDecline to SpecifyOther
Ethnicity

Hispanic or LatinoNative Hawaiian or Other Pacific IslanderNon-Hispanic or LatinoDecline to Specify
Marital Status

SingleMarriedDivorcedLegally SeparatedWidowedOther
Employment Status*

Employed Full-TimeEmployed Part-TimeNot EmployedOn Active Military DutyRetiredSelf-EmployedStudent Full-TimeStudent Part-TimeOther
Occupation
Primary Insurance*
Name and DOB of Insured (self, spouse, etc.) and ID Number
Secondary Insurace
Name and DOB of Insured (self, spouse, etc.) and ID Number
Prescription Insurance (if applicable)
Name and DOB of Insured (self, spouse, etc.) and ID Number
How Were You Referred To Our Office?

Friend or FamilyFamily DoctorInsurance CompanyInternetOptometristOther
Referring Doctor
Primary Care Doctor
Optometrist
Preferred Pharmacy
Include mail order if applicable
Have you fallen 2 or more times in the last year?*
Have you received a FLU vaccine in the last 12 months?*
Have you received the Pneumonia vaccine?*
Do you drink alcohol?*

NoYes, sociallyYes, 1 per weekYes, 1 per dayYes, 2-3 per dayYes, 4+ per day
Do you smoke?*

Never smokedYes, 1 per weekYes, 1 per dayYes, 2-3 per dayYes, 4+ per dayFormer smoker
History of illicit/recreational drug use*
Which drug? How often? How long?
Please check off any CURRENT conditions from which you suffer*

Glasses problemHeadachesGlare/Light SensitivityTired EyesAmblyopia (Lazy eye)BurningDrynessWateringEye Pain/SorenessForeign Body SensationInfection of Eye or LidItchingMucous DischargeDrooping Lid(s)RednessSandy or Gritty FeelingStrabismus (Crossed eye)Blurred VisionHalosDouble VisionFloaters or SpotsFlashes of LightFluctuating VisionLoss of VisionLoss of Side VisionBump on Lid(s)SwellingNone
Severity*
Location*
Timing*
Duration*
How long have you experienced these signs/symptoms?
Vision History*

NoneCorneal DiseaseCataractsGlaucomaCrossed or Lazy Eye(s)Dry EyeMacular DegenerationDiabetic Retinopathy
Previous Eye Surgery*

NoneCataractGlaucomaRetinaLaserRefractiveInjury
Current Eye Drops*

NoneArtificial TearsGel DropsOintmentOther
Medicine Allergies*
Current Medications*
Include prescription AND over the counter medications, including vitamins, Aspirin etc.
Medical Conditions Diagnosed*
Please list ALL conditions for which you take medications and/or have ever been diagnosed
Review of Systems*

NonePrevious eye surgeryContact lens wearerEye PainDouble visionGlaucomaCataractsMacular DegenerationDry EyesFlashes of lightFloatersHard of hearingVertigoChest painDizzinessFainting spellsShortness of breathIrregular heart beatDifficulty lying flatHigh blood pressureHigh cholesterolHeart attackFatigue/weaknessFeverWeight changesCoughCongestionWheezingAsthmaCOPDHeartburnAcid refluxNausea/vomittingJaundice/hepatitisPain/difficulty urinatingBlood in urineHistory of kidney stonesHistory of STIs (sexually transmitted illnesses)AnxietyDepressionBipolarSchizophreniaDifficulty sleepingIncreased hungerIncreased thirstIncreased urinationIncreased sweatingDiabetesEasy BruisingUse of blood thinnersArthritisRash/soresEczemaHivesSeizuresNeuropathyWeakness/paralysisTremorsStrokeTIA
Past Surgeries*
Please list any and all surgeries you have undergone
Has anyone in your family been diagnosed with any of the following:*

NoneAdopted/Don't knowMacular DegenerationHigh blood pressureHeart diseaseHigh cholesterolCrossed or lazy eye(s)GlaucomaRetinal diseaseCancerStrokeArthritisTuberculosisDiabetesKidney diseaseBlindness
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