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Patient Information Form
Patient Information Form
Patient Information Submission Form
"
*
" indicates required fields
Step
1
of
2
50%
Personal Information
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
*
Primary Phone
*
Secondary Phone
Date Of Birth
*
MM slash DD slash YYYY
Patient's Last Four Of SSN
*
Insurance Information
Vision Insurance
Vision Insurance Provider
Vision Insurance ID#
Guarantor Name - Vision
First
Last
Guarantor Date Of Birth
MM slash DD slash YYYY
Guarantor Last Four Of Social
Medical Insurance
Medical Insurance Provider
Medical Insurance ID#
Guarantor Name - Medical
First
Last
Date Of Birth
MM slash DD slash YYYY
Guarantor Last Four Of Social
Medical Questions
Do You Wear Glasses?
*
Yes
No
How Old Are They?
*
How Many Years?
Any Problems
*
Do You Wear Contacts?
*
Yes
No
What Brand?
*
What Type?
*
Daily
BiWeekly
Monthly
Gas Perm
Do You Use The Computer Daily?
*
Yes
No
If So, How Many Hours Per Day?
Please enter a number from
0
to
24
.
Eye Health
Do You Have Any Of The Following?
*
Cataracts
Glaucoma
Eye Injury
Eye Surgery
Lazy Eye / Patching
Double Vision
Dry Eye
Loss Of Vision
Lasik Surgery
None Of These
Medical Health
Are You Being Treated For Or Experiencing Any Of The Following?
Type 1 Diabetes
Type 2 Diabetes
Hypertension
High Cholesterol
Hyperthyroid
Hypothyroid
Cancer
Stroke
Heart Attack
Crohns Disease
Lupus
Arthritis
Allergies
Head Injury
Do You Have Any Allergies To Medication?
*
Yes
No
Please List Any Medication Allergies:
*
Please List Any Medications You Are Taking, Including Over The Counter:
When Was Your Last Physical Exam?
MM slash DD slash YYYY
Do You Smoke?
*
Yes
No
How Many Packs A Day?
*
Do You Drink?
*
Yes
No
How Many Drinks Per Week?
*
Hobbies & Activities
Please Check All Activities That You Participate In:
Tennis / Racket (Raquet) Sports
Computers
Swimming / Scuba Diving
Woodworking / Crafting
Jogging / Running
Automotive / Driving
Basketball / Baseball
Gardening / Lawncare
Hunting / Shooting / Fishing
Music / Reading
Golf
Knitting / Needlework
Cycling
Other
Other Hobbies & Activities