Registration Forms

PATIENT NAME AND INFORMATION

Date of scheduled appointment:

Name:

Last

First

Middle

Salute

Nickname

Social Security

Birth Date:

Gender: Male
Female

Address:

Street Address

Address continued

City

State

Zip

Home Phone Number:

( )

-

Work Phone Number:

( )

-

Mobile Phone Number:

( )

-

Your Email Address:

REFERRING PHYSICIAN/PRIMARY PROVIDER INFORMATION

Doctor/Provider...

	Last	First
Name:

Work Phone Number:

( )

-

Fax Number:

( )

-

PARENT'S or INSURED'S INFORMATION

Name:

Last

First

Middle

Salute

Nickname

Social Security

Birth Date:

Gender: Male
Female

Address:

Street Address

Address continued

City

State

Zip

Home Phone Number:

( )

-

Work Phone Number:

( )

-

Mobile Phone Number:

( )

-

Email Address:

MORE INFORMATION

Main reason for today's visit:

Doctor(s) who should get reports: Please separate using commas.

Phone Number:

( )

-

Fax Number:

( )

-

Do you want examination for glasses or lenses or a prescription for glasses or lenses as part of today's visit/exam? YES
NO

Please note that there is a separate charge for refraction (glasses examination) that is not covered by medicare and by most insurance plans.

MORE INFORMATION

Your eye condition: List any known eye condition you may have, eye surgery you have had (and when):

Medication for your eyes:
YES
NO Please give the dose, how often and what for:

Medication

1.

2.

3.

How Often

1.

2.

3.

Which Eye

1.

2.

3.

What For

1.

2.

3.

MORE INFORMATION

Family History UnknownKnown

Family History

Cataract YesNo

Glaucoma YesNo

Retinal Detachment YesNo

Blindness YesNo

Macular Degeneration YesNo

Diabetes YesNo

Retinitis Pigmentosa YesNo

Other familial ocular disorder

REVIEW OF SYSTEMS AND MEDICAL CONDITIONS-- DO YOU HAVE TROUBLE WITH...

CANCER YesNo

EARS, NOSE THROAT YesNo

HEART YesNo

Chest pain YesNo

Irregular Heart Beat YesNo

High Blood Pressure YesNo

CIRCULATION YesNo

Cold hands or feet YesNo

LUNGS AND BREATHING YesNo

Wheezing or asthma YesNo

STOMACH OR INTESTINES YesNo

KIDNEY AND URINE YesNo

Kidney stones in urine YesNo

Blood in urine YesNo

BONES, JOINTS, MUSCLES YesNo

SKIN YesNo

BREAST YesNo

NEUROLOGICAL PROBLEMS YesNo

Stroke YesNo

Migraine Headaches YesNo

Non-Migraine Headaches YesNo

MENTAL OR EMOTIONAL YesNo

Stress YesNo

Nervousness YesNo

Insomnia YesNo

GLANDS OR HORMONES YesNo

Diabetes YesNo

Thyroid Problem YesNo

BLOOD YesNo

Anemia YesNo

Past Blood Transfusions YesNo

ALLERGIES YesNone

Bad reaction to medication YesNo

Sulfa allergy or bad reaction YesNo

Penicillin allergy or bad reaction YesNo

Food Allergies YesNo

Hay Fever YesNo

OTHER

LAST STEP

Other Medical Conditions: List past and present medical conditions, major illnesses and injuries, hopsitalizations, surgery.

Medications for medical conditions: YESNO

Medication

1.

2.

3.

How Often

1.

2.

3.

Which Eye

1.

2.

3.

What For

1.

2.

3.